Memorial Medical Center fined by state after patient's death

The state has issued a $71,000 fine against Memorial Medical Center after a serious medication error resulted in a patient's death at the Modesto hospital.

The California Department of Public Health released information Thursday on penalties for incidents that jeopardized patients at nine hospitals in the state. The hospitals are expected to pay fines totaling $800,000 for not complying with licensing requirements.

In November 2016, a woman suffering from confusion and kidney failure at Memorial was accidentally given the blood thinner heparin in an amount 25 times the usual dose, a state report says.

The patient, whose name was not released, died early the next morning from massive internal bleeding.

Memorial said Thursday it reported the incident to the state health department and submitted a correction plan to prevent similar mistakes.

"We are committed to the safety of all of our patients and to continuous process improvement," a hospital statement read.

According to a state investigation completed in July, the dialysis patient was admitted to the hospital with blood clots in her arm near a portal used for hemodialysis. She was taken to the hospital's interventional radiology department, where staff attempted to remove the clots.

The patient was given heparin diluted in a bag of saline. A nurse gave a doctor a premixed bag containing 25,000 units of heparin in 250 milliliters of saline or 8 ounces of fluid, thinking the doctor would administer only a portion of the blood thinner in the IV bag, the state report says. The doctor controlled the rate of drip with a clamp.

The normal dose for the procedure was 1,000 units of heparin in 500 milliliters of saline. After the procedure was completed, a radiology technician showed a nurse the empty bag that had contained the heparin, indicating the patient had received the entire 25,000 units.

The woman was taken to the intensive care unit but efforts to save her life were not successful.

The doctor later told a state investigator he did not know the nurse had provided a premixed bag with 25,000 units of the blood thinner. He said that, in his medical practice, a premixed bag of heparin drip is 500 units in 1,000 milliliters of saline.

The state penalized Memorial for not following policies and procedures in administering a high-risk medication.

According to the state report, the hospital removed all the bags with 25,000 units of heparin from cabinets and the drug is now dispensed by machine. It also ensures that new physicians attend pharmacy orientations and that nurses read back verbal medication orders from doctors.

The state has assessed four previous administrative penalties for incidents that jeopardized patients at Memorial.

This story was originally published April 19, 2018 at 4:44 PM with the headline "Memorial Medical Center fined by state after patient's death."