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Chemo death case settled
December 20, 2006, 12:00 AM By Michelle Durand, Daily Journal Staff
San Mateo County will pay $160,000 to the family of Armando Castellanos, a 41-year-old oral cancer patient at San Mateo Medical Center who died days after being given 10 times the correct dose of chemotherapy medicine two years ago.

The settlement falls short of the $1 million the family originally sought. The settlement is considered "to be fair and reasonable under the difficult circumstances of the case," according to a memo from Human Resources Director Donna Vaillancourt.

Hospital spokesman Dave Hook referred all comments about the settlement to Chief Deputy County Counsel John Beiers.

The county's medical malpractice insurance carrier, BETA, decided to settle rather than litigate because liability was never in question, Beiers said.

"It is a matter of public record that this was a tragic error," Beiers said. "The issue was arriving at a fair and reasonable amount for the family."

Castellanos' Aug. 16, 2004 death not only brought a claim by his family but also spurred multiple local and state investigations into the error and changes in the county's whistleblower laws.

In the days following Castellanos' death, the San Mateo Medical Center was knocked not just for the medical error but also not alerting his next of kin about the Cisplatin overdose on Aug. 12 until just before he died. Medical personnel reportedly discovered the mistake -- 500 mg instead of 50 mg -- but stayed mum while Castellanos' health declined. The family was informed of the dosage before they removed him from life support.

Although hospital officials immediately alerted the California State Department of Health Services and the Board of Supervisors, the hospital did not inform Coroner Robert Foucrault about the accidental overdose. With Castellanos' body cremated, Foucrault was forced to investigate the incident without an autopsy. Foucrault is required by law to investigate all unattended or questionable deaths in the county.

The death was not made public until Mark Church, then-president of the Board of Supervisors, made mention of it at a meeting.

After the incident, the Institute for Safe Medication Practices, a private investigation firm hired by the county in September 2004 for $21,000, analyzed what human errors caused Castellanos' death and how to minimize future risk. ISMP ultimately returned a list of suggestions including technological improvements and contracting out certain programs such as infusion services.

Simultaneously, the Coroner's Office and state health department also reviewed the death.

The reports generally agreed Castellanos' death was due to a handful of problems, including difficulty in reading a prescription and poor communication. The trouble began with a doctor's illegible handwriting, continued with clarification of the order not being recorded and a pharmacist misreading the medicine dose on the prescription, according to the ISMP report.

In the reports, Dr. Edgar Pierluissi, medical director of quality improvement, disagreed that the family was not informed of the error, claiming it was "immediately communicated."

In the wake of the death, the pharmacy and pharmacists involved were disciplined by the state board. Church also proposed a so-called whistleblower ordinance to prevent the air of secrecy that initially permeated Castellanos' death. The ordinance requires employees of the Health Services Agency, the San Mateo Medical Center and clinics to report unusual occurrences to their immediate supervisors who in turn must send it up the chain of authority. An internal investigation is spearheaded by the agency or the Board of Supervisors.

Medical errors are estimated to account for up to 98,000 deaths annually, according to a national study by the Institute of Medicine.

Michelle Durand can be reached by e-mail: michelle@smdailyjournal.com or by phone: (650) 344-5200 ext. 102. What do you think of this story? Send a letter to the editor: letters@smdailyjournal.com.


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