Sutter Medical Center in Sacramento has been fined by state regulators over a lethal dose of morphine administered by medical staff, according to a report released this week by the California Department of Public Health.
A patient died after he received 166 times the prescribed dosage of morphine on Aug. 28, 2017, regulators said.
Public health officials levied a $75,000 fine against Sutter, the highest fine allowed in this case of “immediate jeopardy” – “a situation in which noncompliance by a hospital has caused or is likely to cause a patient’s serious injury or death, the report said.
They also worked with Sutter to improve staff training on the use of smart pumps and to help Sutter ensure equipment effectively limits the output of high-risk medications that can harm patients when dispensed inappropriately.
Sutter disagrees with the findings and is appealing the fine, said Amy Thoma Tan, director of public affairs and issues for the health provider.
In a prepared statement, Tan said: “Maintaining a high level of safe patient care is at the heart of our work, and we deeply value the trust our patients place in us to deliver comprehensive, compassionate care. While we respect CDPH’s role as we work together to optimize patient safety, we disagree with the findings and have filed an appeal.”
The state report does not name the patient, his family or members of the Sutter staff.
Regulators said he was admitted to Sutter Medical Center on Aug. 11, 2017, suffering from acute respiratory failure, and was hospitalized for several weeks. On Aug. 27, a doctor prescribed 1 milligram per hour of morphine, and a nurse started a 250 mg drip at 8:54 p.m., the report said.
At 1:25 a.m. on Aug. 28, the patient’s wife told the nurse that the entire IV bag of morphine looked empty, and upon inspection, the nurse found it was, the report said. No alarms had sounded, but the Sutter team later discovered that the morphine infusion had stopped eight minutes after it started, at 9:02 p.m. The patient died at 6:33 a.m. Aug. 28.
After examining the body, the Sacramento County coroner confirmed that the patient had received an excessive amount of morphine prior to death, the report said. The cause of death was listed as a morphine overdose, with the interval between onset and death being just hours, regulators said.
State investigators determined that, while the morphine “smart pump” had not sent an alarm to hospital staff, the hospital’s biomedical engineering team later gathered a detailed report from the infusion pump showing that it had indeed documented an alarm indicating that the morphine was being delivered at an uncontrolled rate, or “free flow.” The machine, however, did not record the alarm code until after a nurse discovered the morphine bag was empty.
The report said hospital leaders did not investigate the possibility of free flow, despite records showing the facility had received prior warnings from the manufacturer that it could happen if tubing was misplaced or if the pump door was damaged or closed improperly. After a review of training materials, regulators also said that nurses were not being alerted to this risk and did not have to document that they had checked for such issues.
Regulators noted that a device called a “volutrol” could help prevent pump free flow, but they said hospital leaders said “there was a shortage of volutrol equipment for all the corporate hospitals to institute such a corrective action.”
Sutter Medical Center took a number of corrective actions after the findings from the Department of Public Health, actions that it stated do “not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in the Statement of Deficiencies.”
Thoma Tan said the correction plan includes additional layers of safety protocols and staff training to further the company’s commitment to patient safety.
“Our sincerest sympathies remain with the patient’s family and loved ones,” she said.
The Sutter fine was one of eight penalties totaling $437,425 that the Department of Public Health announced this week against hospitals around California, ranging from El Centro Medical Center in Imperial County to Adventist Health St. Helena in Napa County.