The inspection of the hospital's drug pumps was prompted by a complaint from the California Nurses Association, which said the patient-administered pain-control drug pumps were malfunctioning.
Inspectors found that the pain-control drug pumps were working properly, but nurses had entered the incorrect dosage.
State inspectors also found that the hospital had failed to adequately train and oversee its nursing staff. A sixth overdose happened while inspectors were on site.
Murray said the first overdose happened in October 2008, with several more in the spring. No patients died or suffered serious injuries because of the overdoses.
The hospital immediately retrained the nurses, assigned expert users to each shift and created procedures to double-check the pumps, hospital spokesman John Murray said.
State health officials accepted the hospital's plan to address the problem, tested some nurses and lifted the warning the next day.
Murray said nurses who use the pumps frequently were trained, but not every nurse used them enough to be proficient. "If a nurse is not comfortable using a piece of equipment, they should find someone who is. The inspectors were asking every nurse to use the pump, whether they used them often or not," he said.
The state investigators filed a report with the CMS, which has not yet signed off on the hospital's corrective plan. CMS investigators will perform a surprise inspection to determine whether the hospital has fixed the problems.
What do you think? Post a comment on this article and share your opinion with other readers. Submit your comments to Modern Healthcare Online at [email protected]. Please be sure to include your hometown and state, along with your organization and title.