UC San Diego officials said they have since held repeat drills with staffers who treat patients with Flolan and examined every step in the process.
Dr. Angela Scioscia, the center's senior medical director, said the public reporting requirement is "a great opportunity to make rapid improvements" because hospitals can learn from one another's problems. "We don't want people to be afraid when they come into hospitals, because they are becoming safer and safer all the time," Scioscia said.
Under the 2006 disclosure law by state Sen. Elaine Alquist (D-Santa Clara), hospitals must inform state regulators of every occurrence of 28 different types of dangerous mistakes. Those include deaths during labor, medication errors, suicide attempts and sexual assaults.
The public health department has until 2015 to begin posting the information on the Internet, although officials said they hope to begin publishing it earlier. The most recent figures available cover the 10 months since July 2007. In that time, 466 patients developed bedsores so severe that the dead skin formed a crater or rotted through to the muscle or bone.
Another 145 patients had foreign objects such as surgical equipment left in their bodies. Thirty-four died while under anesthesia. In 41 surgeries, doctors performed the wrong procedure or operated on the wrong body part or on the wrong patient.
So far, the state Department of Public Health has levied $25,000 fines against 10 hospitals that reported adverse events. Officials said other investigations are still under way.
One hospital, Scripps Memorial in La Jolla, was fined twice for two errors that occurred last November with the same patient. First, as the patient was recovering from surgery, she was given a painkiller that is not supposed to be used after operations. When she went into respiratory arrest, the pharmacist provided a corrective medication at a dose 10 times too weak to be effective.
The patient survived. State investigators discovered that the hospital's pharmacists had not been properly instructed in the use of 10 medications, including the corrective drug, that the hospital stocked for emergencies.
The ventilator error at Stanford's Lucile Packard Children's Hospital occurred because a therapist had assembled the machine by following a diagram that had been drawn backward. Dr. Christy Sandborg, the hospital's chief of staff, said the medical team quickly noticed that the ventilator wasn't working correctly and stopped using it. The child recovered, she said, and the hospital has made changes to prevent future occurrences.
