From KGO TV:
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.