Becker's Hospital Review

46 CMO / CARE DELIVERY 6 hospitals in the spotlight for medical errors in 2019 — and how they're fixing them By Gabrielle Masson S everal hospitals worked to improve patient safety and curb med- ical errors aer reports in 2019 found lapses in patient care that ultimately led to patient deaths. Here are the six hospitals Becker's tracked and how they responded to the patient errors: 1. Baylor St. Luke's Medical Center (Houston). A CMS inspection published Feb. 26, 2019, revealed staff at Baylor St. Luke's Medical Center made more than 100 mistakes in labeling blood over a four-month period, according to the Houston Chronicle. e in- spection was prompted by the December 2018 death of a patient who had repeated heart attacks aer receiving the wrong blood type. e hospital released a detailed plan of correction Feb. 26, 2019, in- cluding revisions of relevant policies; review of documentation pro- cesses in affected areas of the hospital; implementation of an audit process; and educational sessions for physicians and staff. 2. Ben Taub Hospital (Houston). A second patient was found dead July 16, 2019, in a bathroom at Ben Taub Hospital aer waiting for emergency care, three months aer staff found a 66-year-old patient with no pulse in an ED bathroom, according to the Houston Chronicle. George Masi, president and CEO of Houston-based Harris Health Sys- tem, which operates Ben Taub and Houston-based Lyndon B. Johnson Hospital, told the Houston Chronicle that the hospital immediately im- plemented "additional risk reduction strategies" to ensure patient safety. 3. MD Anderson Cancer Center (Houston). A 23-year-old leukemia patient died two days aer receiving a blood transfusion contaminated with bacteria at MD Anderson Cancer Cen- ter, according to a June 24, 2019, CMS report cited by the Houston Chronicle. e report followed the documentation of serious care de- ficiencies at the hospital. e hospital sent CMS a correction plan, implemented new safeguards for blood transfusions and developed ongoing education on blood ad- ministration procedures. 4. WellSpan York (Pa.) Hospital. A patient died at WellSpan YorkHospital's emergency department af- ter being le unattended for more than an hour, according to a state inspection report cited by York Daily Record. Following the incident, state inspectors deemed the facility out of compliance with Pennsylvania's Medical Care Availability and Re- duction of Error Act. e hospital reassigned nurses to ensure 24/7 coverage in triage areas and required nurses to reassess patients in the waiting area when length of stay exceeds one hour, Allan Birenberg, MD, vice president of medical affairs at WellSpan York Hospital, said in a statement cited by York Daily Record. 5. Lyndon B. Johnson Hospital (Houston). A patient at Lyndon B. Johnson Hospital died aer giving birth by ce- sarean section in September 2019, according to a Nov. 8, 2019, CMS report cited by the Houston Chronicle. e report found the C-section patient died aer her heart rate increased and never dropped. Physi- cians never consulted other medical staff about the increased heart rate, and there was no record of the patient's blood pressure or tem- perature being taken. e health system submitted a full plan of correction to CMS Nov. 18. In a statement cited by the Houston Chronicle, Harris Health officials said they are confident that CMS' follow-up survey will find that the corrective actions remedy the deficiencies and meet all agency standards. 6. Geisinger Medical Center (Danville, Pa.). Geisinger Medical Center identified contaminated equipment as the source of Pseudomonas bacteria that killed three infants and sickened five others in its neonatal intensive care unit last fall, e Daily Item reported. Aer the Pennsylvania Department of Health cited the hospital for not having a written policy to clean equipment, Geisinger draed a new pol- icy. As a precaution, the hospital also transferred premature infants and women expected to give birth before 32 weeks to other hospitals. n San Francisco hospital failed CMS reinspection after patient abuse scandal By Mackenzie Bean L aguna Honda Hospital and Rehabilitation Center received additional penalties from CMS, including payment denial for new admissions, after failing a follow-up inspection in September 2019, reports the San Francisco Examiner. CMS cited Laguna Honda in July 2019 after an investiga- tion revealed 23 patients were systematically abused at the city-run hospital between 2016 and 2019. Investiga- tors determined that poor supervision and a culture of silence contributed to the abuse. During a follow-up visit in September 2019, state inspec- tors found the hospital did not give nurses a platform to address concerns, improperly discarded medica- tions and failed to prevent further neglect, according to CMS documents the San Francisco Examiner obtained through a Freedom of Information Act request. As a re- sult, CMS denied payment for new admissions and im- plemented a daily fine, among other penalties. Instead of halting new admissions, the hospital accept- ed 21 new patients during this period. Laguna Honda planned to cover about $126,000 in unreimbursed care costs for these patients, Rachael Kagan, director of com- munications for the city's Department of Public Health, told the San Francisco Examiner in November. State inspectors returned to Laguna Honda in mid-October and found the hospital in compliance with all regulations. n

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