UC San Diego Health fined over fatal heart monitor incident

The California Department of Public Health fined UC San Diego Health $44,000 after a medical mistake involving an inactive cardiac monitor led to a patient's death in September 2015, The San Diego Union-Tribune reports.  

The penalty is one of 10 citations totaling $549,555 the agency bestowed upon nine California hospitals Dec. 28.

According to a statement of deficiencies released by the state, a male patient recovering from an angioplasty procedure at UC San Diego Medical Center-Hillcrest died after the cardiac monitor supervising him failed to open a clogged blood vessel and relieve chest pain. The patient was disconnected from the bedside device around 5:44 a.m., Sept. 8, 2015, The San Diego Union-Tribune reports.

A technician monitoring the heart signals from multiple patients in a separate area of the hospital told state investigators he didn't notice the patient's heart rate flatline because the screen showing that data "was off to the side. I just didn't scan over that far," according to The San Diego Union-Tribune. The technician added he didn't hear the bedside monitors' alarms, and his remote-monitoring console made no automatic warning sound.

A nurse assigned to the patient said he heard the alarm "for only about 10 to 15 feet" in the hallway outside the patient's room. He didn't check on the patient until 6:35 a.m., at which point the patient looked "gray and unresponsive," according to the state's report.

The state claimed UC San Diego Medical Center did not have a detailed enough written procedure for its monitoring technicians and the annual training assessment of that morning's technician on duty was not verified. In its report, the state wrote the hospital's efforts were "informal, inconsistent and failed to ensure patient safety and well-being."

In a statement to The San Diego Union-Tribune, UC San Diego Medical Center said it immediately revised its guidelines and trainings "to ensure successful implementation of these corrective actions." The statement adds that "UC San Diego Health's commitment to the health and safety of its patients is absolute and on-going."

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