SACRAMENTO — Last October, a technician at the children's hospital at Stanford University improperly connected a ventilator hose, accidentally pumping too little oxygen into a 9-day-old infant's lungs.
A month later, technicians at Dominican Hospital in Santa Cruz unintentionally placed a CT scan of one patient into the electronic file of another, leading physicians to remove the wrong person's appendix.
Last March, Virginia Fahres, 76, died at Pomona Valley Hospital Medical Center in Pomona after a nurse gave her two drugs, neither of which her doctor had prescribed.
Those incidents were among 1,002 cases of serious medical harm disclosed by California hospitals between July 2007 and May of this year. The disclosures are the first under a state law that requires hospitals to inform health regulators of all substantial injuries to their patients.
Officially called "adverse events," those accidents are also known as "never events" because they are considered preventable, and many safety experts say they should never happen. California patients are being injured at a rate of about 100 a month, according to data compiled by the state Department of Public Health.
"I think the never events are a wake-up call to everyone about the safety of California hospitals," said Beth Capell, a lobbyist for Health Access California, a consumer group.
Revelations of such errors have led lawmakers and hospital associations in at least seven states to protect patients from having to pay for the cost of care that went awry. In Sacramento, an assemblyman proposed a ban on reimbursing hospitals for the types of injuries tracked by the state. But when lobbyists for doctors and hospitals objected, he scaled it back to cover far fewer errors.
Four million people were admitted to California hospitals last year. State investigators found some errors occurred because hospitals failed to follow safeguards designed specifically to prevent harm.
Last July at UC San Diego Medical Center, a patient died after a nurse incorrectly programmed a medicine pump that then delivered more than twice the appropriate dose of a specialized blood pressure drug. Regulators found that the hospital's administration had been warned earlier by its own safety committee that "errors continue to occur" with that type of pump but had not taken sufficient corrective action, according to a state probe.
