UCI hospital warned over drug pumps

State inspectors investigating claims by nurses that faulty drug pumps had led to the accidental overdose of five patients at UC Irvine Medical Center found three deficiencies and issued an “immediate jeopardy” warning, alleging that patient care was at risk, hospital officials acknowledged Thursday.

The warning earlier this summer is one of the most serious that can be issued against a hospital -- and typically federal or state inspectors stay on site until a plan to correct the problem is in place. In UCI’s case, the July 13 warning was lifted within 24 hours.

UC Irvine Medical Center’s chief executive, Terry A. Belmont, disclosed the findings by the U.S. Centers for Medicare and Medicaid Services in an e-mail sent to the staff Thursday.

Belmont said the hospital took the findings seriously. “Though CMS found that no patients suffered irreparable injury, we must and will do better to keep those in our care safe,” he wrote.

The July inspection came as a result of a complaint filed by the California Nurses Assn. alleging that the hospital was using faulty pain-control drug pumps that led to the accidental overdose of five patients.

State inspectors investigating on behalf of the federal agency found that the pumps did not malfunction, but that nurses had input incorrect doses.

Inspectors faulted the hospital for inadequate training and oversight of the nursing staff.

While inspectors were on site, a sixth drug overdose occurred.

Health authorities said the hospital had failed to monitor its own action plan to prevent additional incidents.

No patients died or suffered serious injury as a result of the overdoses.

Since the inspection, the hospital has filed a plan of correction, which included retraining every nurse on use of the pumps and establishing “super users” considered experts on the devices. Those “super users” are nurses or pharmacists who have completed training and demonstrated excellent skills. At least one “super user” will be assigned per shift, per unit.

The hospital also purchased 110 of the pump’s newest model, which includes a software upgrade designed to help protect against accidental overdoses.

Nurse Sharon Speck, a member of the state nurses association, questioned why it took a complaint by staff to force change, but said she is pleased with the results.

“As nurses, we want to keep our patients safe. One of the ways we can do that is to advocate when something goes wrong,” Speck said. “We do have a new CEO. And we do have a new interim [chief nursing officer], so I think we have to give them a chance. They did work very hard to rectify the problem.”

Federal health authorities have not yet signed off on the hospital’s corrective plan. A spokesman for the agency said investigators will perform a surprise inspection to ensure that the hospital has corrected the problems.

In the last year, federal inspectors have issued multiple citations against the hospital, including for problems with the anesthesia monitoring system.

Belmont, who became chief executive in March, said he is establishing more oversight systems to avoid problems like the ones that arose with the drug pumps.

“When we say we’re going to do something, we do it,” Belmont said. “Going forward, that’s what we’re going to do.”

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