Improper Use of Drug Pumps Caused Patient Overdoses at So. Cal. Hospital, State Inspectors Say

California state health inspectors recently issued an “immediate jeopardy” warning to the UC Irvine Medical Center in Southern California after discovering that improper use of computerized drug pumps caused six patients to suffer accidental overdoses of pain-killing medications.

The warning was issued in July and lifted within 24 hours after the problems were fixed, officials said in making public the shocking development. The Los Angeles Times reported the issuing of the warning today.

An “immediate jeopardy” warning is one of the most serious warnings state inspectors can issue against a hospital and pretty much means what it says; that the problems at the hospital are serious enough to place patients in imminent risk of serious injuries if not corrected immediately.

Terry A. Belmont, the executive director of UC Irvine Medical Center, revealed the findings by the U.S. Centers for Medicare and Medicaid Services in an e-mail sent to hospital staff, the Times reported.

“The efforts of CMS and other regulatory agencies are important for quality assurance and we take their findings seriously,” Belmont wrote, according to the Times. “Though CMS found that no patients suffered irreparable injury, we must and will do better to keep those in our care safe.”

Nurses’ Complaint Prompted State Inspection

State inspectors went into the UC Irvine hospital to follow up on a complaint from the California Nurses Association, which accused the hospital of using defective devices to deliver pain medications to patients. The nurses’ complaint stated that the use of the devices had resulted in the accidental overdose of five patients.

However, inspectors said the problem was not malfunctioning pain pumps, but rather, that nurses had inputted the wrong dosing information into the devices. The hospital was found to have inadequately trained nurses then failed to properly supervise their use of the pain pumps. While state inspectors were still on site looking into the causes of the five overdoses, a sixth UC Irvine patient suffered an accidental overdose caused by improper use of the pain pumps, officials said.

None of the patients died or suffered serious injury as a result of the overdoses, according to the Times report.

Improved Training Measures Implemented

UC Irvine has since improved training and solved the problems with the pain pumps, officials said. Part of the plan to improve administration of pain-killing drugs through pain pumps included designating some employees as “super users,” who are considered experts on the devices.

Those “super users” are nurses or pharmacists who have completed training and demonstrated excellent skills. At least one “super user” will be assigned per shift, per unit, the Times reported.

The hospital also purchased 110 of the pump’s newest model, which includes a software upgrade designed to help protect against accidental overdoses. Federal health authorities must still approve the hospital’s corrective measures, and that likely won’t happen until at least one surprise inspection of the hospital is conducted to see if the accidental overdoses problems really have been fixed.

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