Medication Nation

http://www.sacbee.com/101/story/801193.html

By Christina Jewett - cjewett@sacbee.com

Last Updated 2:52 pm PDT Thursday, March 20, 2008

A Sacramento psychiatric hospital was fined $25,000 Thursday by the state for giving one patient 10 times the suggested dose of the wrong medication, records show.

State and federal public health inspectors discovered the medical error during a follow-up visit to Sierra Vista Hospital after a woman died in 2005 at the hospital after being improperly restrained, reports say.

A Sierra Vista spokesman declined to comment.

Follow up:

The two psychiatric hospitals were among a total of 20 hospitals that have been fined $25,000 since a law enacted in 2006 gave officials the fining clout.

Kathleen Billingsley, a deputy director of the state Department of Public Health, said in a conference call Thursday that the penalties are meant to remind hospitals to be vigilant about patient care.

“We firmly believe this leads to improvement to patient health and safety throughout the state,” she said.

The first round of fines hit nine hospitals, five of which appealed the penalties. The penalties announced Thursday affect 11 hospitals, including Kindred Hospital in Modesto, which was hit with $75,000 in fines.

The hospitals were penalized after inspectors come across events that put patients in “immediate jeopardy” of serious injury or death, officials said.

The alarming incident at Sierra Vista involved a 29-year-old woman who was involuntarily admitted to the psychiatric hospital.

On March 16, 2007, she was given an overdose of a drug. A single dose can lead to side effects ranging from difficulty talking to a coma, the report says. The woman’s husband visited the woman the day after the medical error and found her “completely sedated,” he wrote.

“At first she could not wake herself up enough to to drink water or eat any fruit…” the report by state public health and federal Medicaid inspectors recounts. “She poured water into her mouth but it just dripped out.”

Sierra Vista came under scrutiny by inspectors in late 2005 after Ramona Knapp, 51, died in an incident that coroner’s officials called a “restraint asphyxia” homicide.

On the night of Dec. 3, 2005 Knapp ran around and shouted, a public health report says. A staff member pinned her to the floor and leaned on Knapp’s back for about five minutes, the coroner’s report says.

Knapp died within days. State inspectors wrote in a September 2006 report that staff restrained Knapp inappropriately.