OLIVE VIEW INCIDENTS INVESTIGATED 1 PATIENT CATCHES FIRE, 1 DIES FOR LACK OF ANTIDOTE.

Byline: TROY ANDERSON

Staff Writer

California and Los Angeles County health officials said Friday they have launched investigations into three incidents at San Fernando Valley's Olive View UCLA-Medical Center, including one in which a patient died.

The cases all occurred over the past two weeks at the center, long considered the "crown jewel" of Los Angeles County's public hospital system.

In one case, a surgical device caught a patient on fire; in another, an Office of Public Safety commander refused to pick up an antidote at a nearby hospital -- and the patient died from oleander poisoning.

"No one should rush to judgment on any conclusions about the quality of care at Olive View," said James Lott, executive vice president of the Hospital Association of Southern California.

"This is a major medical center that treats a whole lot of patients, and things like this, though unfortunate, do happen."

The state Department of Public Health and the county Department of Health Services are investigating, and the county has already taken preventive measures.

County Supervisor Michael D. Antonovich said changes already have been made to the electrosurgical equipment involved in the fire incident.

"That was a freak accident, but we are taking actions to prevent this type of thing from occurring in the future," he said.

The Office of Public Safety also is investigating the commander who refused to pick up the antidote at a nearby hospital.

If the allegations are true, "it was an act of insubordination and he needs to be fired and held criminally liable," said Antonovich, who has asked DHS Director Dr. Bruce Chernof to give a full report to the Board of Supervisors on Tuesday.

The investigations come only two months after federal officials announced that long-distressed King-Harbor Hospital failed a critical inspection after a spate of deaths. The hospital lost $200 million in funding, and the Board of Supervisors subsequently decided to close its emergency room.

Some employees who passed competency tests were transferred to Olive View, but Antonovich said none of those were involved in the recent incidents at the Sylmar hospital.

"Olive View has an excellent reputation, has provided excellent health care to the population it serves and it remains an excellent facility," said Dr. David H. Aizuss, president of the 5,000-member Los Angeles County Medical Association.

"Patients catching fire during surgery usually indicates that there has been some procedural error during preparation of the patients -- the device isn't grounded properly or it could have been a problem with the device itself."

In a memo to the Board of Supervisors, DHS Senior Medical Director Dr. Robert Splawn wrote that an electrosurgical device sparked the fire Sept. 24 during a procedure to remove a benign growth from a patient's face.

The fire was extinguished, but the patient suffered first- and second-degree burns to the face and was hospitalized, but has since been released. The patient is expected to recover fully with minimal, if any, scarring.

In the second incident, on Oct. 1 an ambulance brought a man to the hospital who told paramedics he had ingested poisonous oleander.

The treating physician ordered 10 vials of the antidote, Digibind, but only three were available in the hospital pharmacy's "night locker." The patient went into cardiac arrest before the antidote was administered.

The pharmacy operates from 7 a.m. to midnight, and during off hours, a pharmacist is on call to respond to emergencies, but was not contacted.

Instead, the hospital asked a nearby hospital to share its antidote. The watch commander at Olive View was asked several times to pick up the antidote, but refused, Spawn wrote.

The hospital nursing supervisor arranged for another staff member to pick it up. The antidote was administered more than 50 minutes later, but the patient died.

"Depending on the time of day, it's not uncommon that police officers are used to facilitate transports of this nature," said OPS Health Services Bureau Lt. Michael Rich. "It doesn't happen very often, but it has happened before."

In response, the hospital has increased its stock of the antidote and plans to keep the pharmacy open 24 hours a day starting next month.

The third incident occurred Sept. 25 when a pregnant woman with toxemia underwent a C-section. But there were complications, and the baby had to be resuscitated. The state's initial review of the case indicated the outcome could not have been avoided.

DHS spokeswoman Maeve McConnell said Olive View is a good hospital and wanted to release information about the incidents because of inaccurate rumors.

"It's an excellent institution," DHS spokesman Michael Wilson said. "We have three unusual cases that have happened, but the appropriate actions were taken."

troy.anderson(at)dailynews.com

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