The California Department of Public Health has fined Valley Children’s Hospital $71,962.50 in the death of a patient two years ago.
The state says a delay in communicating the results of a chest X-ray and scan resulted in a delay in medical treatment and surgery, resulting in the potentially avoidable death of the young man who died from a bleeding aneurysm.
No information about the patient’s age or hometown was immediately available, but the state identified him as male and Valley Children’s identified him as a “young adult.” Valley Children’s treats patients up to 21 years of age. He died on Nov. 6, 2015.
The state said the young man had major injuries after a traffic accident on Aug. 15, 2015, and received care at a hospital for a brain injury, abdominal injuries, removal of his spleen, chest wounds and a fractured left leg.
On Sept. 16, 2015, he was transferred to Valley Children’s Hospital for rehabilitation and was sent home on Sept. 23. He returned to Valley Children’s emergency department at 12:13 p.m. on Oct. 3, complaining of “left shoulder pain, stomach pain with vomiting and chest discomfort with difficulty breathing,” the state report said. A doctor ordered a chest X-ray and a computerized tomography scan of the abdomen with a contrast dye to improve visibility.
According to the state report, a radiologist read the chest X-ray and recommended a chest scan with contrast dye be done to help define an abnormality seen in the X-ray. The radiologist left the hospital at 6 p.m. and the next morning found that the chest scan had been done without contrasting dye – and that a contracted radiologist who had read the scan during the night had noticed the deformity and had recommended a scan with dye.
That morning, the radiologist said he was going to call the patient’s admitting doctor about the recommendation for a scan with contrast dye, but “was distracted by another call and didn’t call a report.” A copy of the report was sent electronically to the doctor, but a follow-up to see if the chest scan with contrast dye had been ordered was not done.
The patient’s admitting doctor said he was not aware the young man had had a chest scan and did not see the electronic report. The state said the doctor was very distressed to learn that the patient had returned to the hospital on Nov. 6 and died in the emergency department as a result of an aneurysm on his heart. An aneurysm is a blood-filled bulge of a blood vessel.
The admitting doctor told the state that “several areas of missed opportunities occurred; not doing a CT scan with contrast as recommended by the radiologist; not following up on the CT scan in the (emergency department) on the next day; and assuming a discussion about the abdomen (scan) … covered all the information I needed to treat (the patient).”
We immediately assembled a team to review the events in detail, established processes to prevent something like this from happening again, and educated our doctors, nurses and staff.
Todd Suntrapak, Valley Children’s Hospital
When the state penalizes hospitals, it requires them to provide a plan of correction to prevent future incidents. Hospitals can appeal an administrative penalty by requesting a hearing within 10 calendar days of notification. If a hearing is requested and the penalty upheld following an appeal, the penalties must be paid. Valley Children’s submitted a plan of correction. It is not appealing the penalty.
Todd Suntrapak, president and CEO at Valley Children’s said in an email Thursday: “In the fall of 2015, Valley Children’s lost a patient and we were devastated by what happened. At that time, we met with the family and shared what we had learned. Our condolences were with the family then and remain with them today. We immediately assembled a team to review the events in detail, established processes to prevent something like this from happening again, and educated our doctors, nurses and staff.”
Suntrapak said the hospital has shared the information with “other hospitals and healthcare networks with the goal of educating their care teams on how to prevent similar situations from occurring. We are committed, each and every day, to improving patient safety and quality of care at Valley Children’s.”
This is Valley Children’s first administrative penalty.
The state cites hospitals for problems considered to be an “immediate jeopardy” in which the health and safety of patients was placed at risk. The California Department of Public Health has been citing hospitals for incidents since 2009.
The fine assessed to Valley Children’s was one of 10 penalties issued to hospitals Thursday for a total of $618,002 in fines. The state can fine a hospital up to $75,000 for the first administrative penalty, up to $100,000 for the second and up to $125,000 for every subsequent violation within three years.