Kaiser faulted in second death

Hart was supposed to receive a dose of epinephrine followed by a dose of Vancomycin two hours later, but an unnamed nurse accidentally brought two doses of epinephrine, according to the report.

About five to 10 minutes later, Hart's heart rate and respirations increased and a physician was called. Hart died later that night.

The nurse failed to follow a hospital policy that requires nursing staff to check medications’ labeling before giving it to patients, the investigation concluded.

Hart's death was the first of two caused by hospital staff incompetence at Kaiser Permanente facilities in a little more than a month in the South Bay.

A 21-year-old San Jose man died Aug. 29 at Kaiser Permanente's Santa Teresa Medical Center, three days after a physician injected him with the wrong medication.

Christopher Wibeto, who was diagnosed with non-Hodgkin's lymphoma, was given the wrong chemotherapy drug on Aug. 26, a report by the state health department determined.

The state agency deemed both hospitals deficient and required policy changes as a result of both deaths.

Those policy changes required registered nurses to double check high-risk medications for accuracy before administering them and asked that staff members at both hospitals receive new training to avoid similar tragedies in the future.

"The deaths that occurred at Santa Teresa and Santa Clara are extremely rare and terribly tragic. Kaiser Permanente has accepted full responsibility, and we have expressed our regret and sympathy to both families,” hospital officials said in a prepared statement.

"We take very seriously our responsibility to learn from these errors and improve our systems,” the statement read. "We have reported both of these deaths to the Department of Health Services and have cooperated fully with their investigations. We also carried out full and thorough investigations, and have added additional safeguards to our pharmacy and medication practices.”

Kevin McCormack, communications manager for Kaiser, said he couldn’t comment further on the incidents or provide more specific details on the policy changes implemented in their wake.

Multiple local hospitals also declined to comment on their policies and safeguards aimed at preventing similar outcomes.

There is no provision in state law that allows the state health agency to levy a fine against hospitals, Lea Brooks, spokeswoman for the California Department of Health Services, said today. The agency can only require that new guidelines and policies be put in place to limit preventable deaths in the future.<