UPMC Cited in Patient Death

By Walter F. Roche Jr.

Multiple errors by staffers at a major Pittsburgh hospital led to the death of a cardiac patient, according to a report by the Pennsylvania Health Department.
The 18-page report on UPMC Presbyterian Shadyside just made public this week states that one patient was found dead several hours after a cardiac monitor became disconnected.
The patient, who was suffering from coronary artery disease, was admitted on May 24 at 9:52 a.m.
A cardiac monitor was ordered at 5:23 p.m., but it didn't become active till 7:45 a.m. the next day. A review of records showed the lead became unplugged at 11:32 a.m., but no action was taken despite an alarm going off.
The patient was found at 3:52 p.m. without a pulse.
"No alarm was triggered to alert staff that MR1 (the patient) had an acute event that required an emergent response," the report states.
The facility "failed to ensure there was sufficient nursing supervision to ensure the patient's cardiac status was continuously monitored," according to the report.
In fact a review of records for 11 cardiac patients showed staffers failed to conduct twice daily cardiac assessments.
In the cardiac patient's case, the hospital also was cited for failing to inform the family about what had happened within seven days of the discovery of the reportable event. The family was finally informed on June 27
The surveyors noted that the hospital also failed to notify the family of another deceased patient (MR12) of the adverse event within seven days.
"Review of MR12 revealed a serious event causing a return to the operating room and contributory to the patient's death was identified on April 3. Review of family notification revealed a letter to the family dated June 3," the report states.
The hospital also was cited for the care provided to another patient who ended up in kidney failure
The report states that the patient had normal kidney function when he was admitted, but suffered acute renal failure when staffers failed to monitor test results as ordered by a physician.
Dosing and blood levels, the report states, were consistent with vancomycin poisoning.
The hospital "failed to administer drugs and biologicals according to a physician's order," the state inspectors reported.
The hospital filed a plan of correction including immediate re-education of staff on the requirements for cardiac and test monitoring. Under the plan audits are to be conducted to assure staff compliance.
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