Duke Hospital Probe Finds FlawsMay 26, 2003 | AP
A government inspection of Duke University Hospital found its dialysis unit used outdated water processing equipment, while one patient received improper medication, a hospital's executive says.
Hospital Chief Executive Officer William Fulkerson issued a memo to hospital managers Friday to discuss "the most significant deficiencies" identified in a weeklong probe of the hospital in March.
"We take this all very seriously," Fulkerson said. "We have been working very hard in the last couple of months to make things better, to go over and beyond what is required."
State inspectors, acting on behalf of federal Medicaid and Medicare programs, first inspected the hospital's transplant programs after Jesica Santillan died of complications at Duke from a botched heart-lung transplant.
A second inspection was performed in late March to examine the hospital's overall care.
During the second inspection, Fulkerson's memo said the hospital had fallen into "immediate jeopardy" of losing its ability to treat Medicaid and Medicare kidney dialysis patients after state inspectors found inadequate safeguards on equipment.
The equipment needed to bring the hospital into full compliance was installed in April, Fulkerson wrote.
Fulkerson said the hospital used an older treatment system that had not resulted in any problems with patient care. He said officials weren't aware that the new system was required.
The memo also said regulators saw the need for Duke to improve documentation for patient end-of-life decisions and patient grievances.
The regulators also found one instance, out of 84 records reviewed, where a patient received the wrong medication because the identification band on a patient's arm was not checked. The patient didn't suffer any ongoing or long-lasting harm, the memo said.
The inspectors issued a 54-page list of deficiencies after the February inspection. The report mainly found fault with five categories of regulations within the hospital's organ-transplant procedures.
Santillan, 17, died Feb. 22 after receiving a second heart-lung transplant at Duke. The hospital transplanted organs of the wrong blood type the first time.
Procedural errors have been blamed for the mistake. Duke has said that the transplant surgeon also assumed wrongly that the donated organs for the first transplant matched Jesica's blood type.
The March inspection report will be made public soon, a federal official said Friday.