The original story was published by KGO TV and is no longer available on its website.
Federal Report On Kaiser Infant Death
By Karina Rusk
Jun. 8 – KGO – ABC7 News has obtained the federal report on a tragic infant death at Kaiser Santa Clara. We were the first to report on the tragic death earlier this year.
The 19-page report focuses on an infant death in February caused by medical mistakes at Kaiser Santa Clara. ABC7 obtained the investigation into the deadly medication error and Kaiser’s response through the Freedom of Information Act.
Kaiser previously told ABC7 News the seven-week-old boy died as a result of human error that originated in the pharmacy and resulted in an overdose of medication.
State Department of Health and Human Services investigator, Glenn Koike, along with two independent consultants were in charge a of a federal investigation that put the hospital on notice . It could lose its Medicare and Medicaid funding.
Their investigation outlines numerous failures in the pharmacy from policies and procedures to responsibility and oversight.
The federal investigation concludes, “the hospital must develop, implement and maintain an effective ongoing, hospital-wide, data driven quality assessment and performance improvement program.”
Kaiser is required to submit a plan of correction showing it has or is in the process of taking action to reduce medical errors. While the HMO cites some changes in auditing and training, Kaiser’s repeated response in the document is this, “the hospital’s further review of its policies and procedures indicated no systematic pharmacy problems and the hospital is providing quality care in a safe environment.”
The information in this report is so new, federal investigators say they need time to review it before commenting on weather Kaiser’s plan of correction adequately addresses their concerns.
If federal and state agencies are not satisfied with Kaiser’s response and actions, the federal government could suspend Medicare and Medicaid funding to the facility — the harshest of sanctions. Kaiser Santa Clara could also become the first hospital under a new state law to face a penalty of up to $25,000 dollars.
Late this afternoon, Kaiser Santa Clara made its chief operating officer available to us. Susan Murphy again stressed the numerous quality control measures in place at the hospital and did say that one specific modification was made in the way the pharmacy handles the weighing of dry medication which ultimately lead to the newborn’s death.
Susan Murphy, Kaiser Santa Clara COO: “We now have a pharmacist only who will have the responsibility for weighing and we will have double checks conducted so that we can be certain that even though it’s a pharmacist doing it, that is is being done correctly.”
Federal investigators in San Francisco indicate they may have some reaction to Kaiser’s plan of correction as early as next week.
Previously:
The big problem with all the risk management jargon about “plan of correction” and “errors” is that it totally leaves out the criminal intent that is behind some of the so-called “errors.” Such as letting an overdue pregnant woman who is at high risk go way longer than she should and not give her a C-section in time. I do not see that as an “error” that Kaiser can produce a “plan of correction” for.
“Plan of correction” is what all the risk management “patient safety” hospital people cry as their claim of innocence, but it ignores the many purely criminal acts that happen under their management. It makes me sick every time I read that phrase, “plan of correction.”
Kaiser *needs* to lose their Medicare and Medicaid funding so that it can be a testiment to all the other hospital systems who thihk they can likewise get away with murder by having a “plan of correction.”
I agree with the above…..Kaiser’s new COO, Sue Murphy, was recruited from Santa Clara Valley Medical Center…. it was a blessing when she left (so it is no surprise that she went to Kaiser)…..I guess it shows her reported ideas of ‘guality of care’ *do* fit their standards.
Quality of Care and Kaiser should never be mentioned in the same sentence…..unless it states that “Kaiser has consistently NOT met the standards for quality of care and thus their license has been revoked.”
The federal investigation concludes, “the hospital must develop, implement and maintain an effective ongoing, hospital-wide, data driven quality assessment and performance improvement program.”
The above quotation is important. My own issue is in front of the Medical Board and the DHS currently and I hope to elaborate on it further in the media soon since it is very unlikely that I will get mediate/arbitrate with them. Kaiser lacks over-sight because their is something fundamentally wrong within the culture of the organization – essentially they are practicing “defensible” medicine which isn’t based in truth and facts but is aimed at practicing medicine at the lowest common denomitor. It is easy to say that something is “acceptable within the standard of care” when those standards are written by your own organization and are lax enough not to cause internal rancor and discord. When they do this, all the QA and Med-Legal processes that should function as oversight become mechanism of justification and obstructionism. Why is that no one ever gets fired at Kaiser when something bad happens. Why do the wagons circle to protect and preserve themselves at all costs – why is self-preservation more important as an organizational value than basic decency. They race around and pay lip service to improvements and maybe a couple of administrators change hats but there is no accountability. I think that someone should step-in and review all QA and M&M reports to stop Kaiser’s self-serving rubber stamp committee approach to reviewing problems. And the watch dogs should be that instead of being pitt bulls subservient to the master only.
The questions you are asking are very good questions. It is disturbing and appalling that these issues are continuously being swept under the rug. You would think, by Kaisers actions, that the truth is not really important at all. Good, quality care couldn’t possibly be provided without accurate information to begin with. Kaiser is preventing good, quality care at the most basic level. They give new meaning to the term preventative care. They are preventing care.
It appears that the healthcare industry and ESPECIALLY Kaiser is forcing us all into a do-it-yourself-care in the express checkout line. What exactly is the point of “healthcare” with such a sloppy attitude and calloused disregard for peoples lives.
I wouldn’t call that healthcare.
I’ll be eagerly awaiting to see what kind of effort they put into digging up dirt from my medical history. I wish them luck since they won’t find much that could possibly validate the negligent and untimely death of My baby. Negligence that comes from a careless, cheap and sloppy way of doing business. Let’s just see if their sloppiness filters over into the arbitration process as well. My guess is that they are much more alert and on the ball when it comes arbitration time. And it also appears that they are very alert and reactive when it comes time to be put in the spotlight by the media.
Great points anon and Beth, you hit the nail right on the head.
I always like to point out how Kaiser put much more money and effort into denying my complaints than they ever put into fulfilling their so called mission to provide me with quality health care. Talk about twisted priorities.
I have been echoing the above statements for well over a year. One of the biggest issues I had when I still had some influence in methodological adherence and quality assurance with HealthConnect is that Kaiser, at a base fundamental level, does not provide a normal best-practice level of oversight to their projects and their inherent corporate structure is one in which ownership of all issues is both deferred and ambiguous–thus making it problematic to assign blame.
As a result, it is difficult to track and quantify the myriad of potential problems that may happen (and which I believe are likely to happen) since the wagons circle one another in a continuous loop. However, avoidance of responsibility should not be condoned (which is exactly what has been happening) as it only serves to make Kaiser more and more profitable and inspire them to concurrently provide sub-standard levels of service in order to maximize profits.
This is a cost driven model and the primary business drivers are based on reducing internal costs while maintaining consistent revenue streams.
I have been trying for several months to make this (the systemic failures as they relate to POTENTIAL–this is the BIG WORD–issues impacting patient safety) a legal issue but I cannot (as of yet) interest anyone in pursuing it.
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