Some quick, relatively unfiltered thoughts:
1. The first I knew about this was last night at about 10:30pm. I am going to find out whether that's a problem or not by reaching out to people who fill out these types of forms and deal with the State. They can tell me whether the Board should have been or was informed (it happened prior to my election) and whether there would have been advance warning of the fine. If I should have known about it before the news report then that is obviously a problem.
2. This was one fine for multiple patients. Not all of the patients in the report were of the same level of concern. Just by reading the report (and I do not know to what extent the report is one-sided), in my opinion, the case of patient 2 is clearly malpractice (my opinion only). Keep in mind that patient 2 was hospice and likely unconscious so I am not sure how much loading him up with an inappropriate dose of narcotics hastened his death, but it appears, from the report, that it did.
3. I know that the interim pharmacy director has been terminated, but I do not know who the other people identified only by number are. Therefore, I do not know what action may have been taken. I have barely skimmed the "plan of correction" side of the report so it may be right there in the Hospital's response.
4. I will be inquiring as to whether there are any other 2567 plan of corrections that have been filed in the last two years to try to minimize surprises like this in the future.
In summary, clearly things went wrong and it was a process problem and not a single incident. Hopefully, the Hospital has made the necessary changes; the State has approved the plan of correction so it appears that they are satisfied for now.
Of interest, this report and fine relates to the same time period in which I was admitted to Alameda Hospital ED wherein the ED physician prescribed---a person who never even takes an aspirin----a lethal does of 2 to 4 milligrams of Dilaudin, where the dose is meant to me .2 (point 2) to .4 (point 4) milligrams. The nurse told me he was going to give me the 4 milligrams; I saved my own life that day when I insisted he begin with the lowest dose possible; he still gave me the 2 milligrams when he should have know .2 was correct. He then left me to languish for several hours; it was not until the next shift and the next nurse that anyone noticed something was awry. By the hospital administration's own definition, I should have died; they don't know why I did not. That was May 2010.
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