An anesthesiologist at Mercy Hospital Southwest who stated he was "in a hurry" accidentally injected heart failure medication, rather than the numbing medication he intended, into the back of a woman about to give birth by cesarean section, according to the California Department of Public Health.
The state agency penalized the hospital, citing the possibility that the error could have caused death or severe disability.
The agency issued the penalty Tuesday after it found that the hospital "failed to implement its policy and procedure to prevent the wrong medication from being administered." The hospital was fined $83,250.
"Patient care and safety are always our highest priorities, and we take this matter very seriously," said Jessica Neeley, a Mercy Hospital Southwest spokeswoman. "We have conducted a thorough investigation and are working closely with the medical staff, patient care staff, and hospital leadership, as well as with the California Department of Public Health to ensure that an incident like this does not happen again."
Mercy Hospital declined to comment on the status of the patients or the anesthesiologist involved in this case due to patient privacy laws and hospital policy.
According to the agency, the patient was taken into an operating room on Aug. 16, 2018, for a scheduled C-section. She was given an initial spinal block — an injection into the spine to cause numbness from the waist down — but required a second after the first was deemed ineffective.
Instead of administering bupivacaine, a numbing agent, into her spine, the anesthesiologist injected digoxin, a heart failure medication, and the woman became unresponsive. She began to have seizures and was admitted into the intensive care unit, the agency said.
The woman's pupils became dilated and her heart rate and blood pressure elevated, and a registered nurse noted that the woman had multiple seizures. The woman was transferred to a neurology intensive care unit two days later, as she was "completely obtunded," or less than fully alert or responsive.
The woman has been discharged from the hospital and will undergo outpatient neurological rehabilitation. A Mercy Hospital Southwest representative declined to characterize her present condition.
Digoxin is a cardiac medication that is extremely toxic to the nervous system, the agency said.
This is the hospital's second "immediate jeopardy" administrative penalty. That designation means the hospital has previously been in noncompliance with the requirements of its licensing to the extent that its actions could or were likely to cause a patient's death or serious injury.