Broken Bed Alarm Blamed for UCSD Walkaway Patient's Death

Broken Bed Alarm Blamed for Walkaway Patient's Death
Thomas Vera died after he became disoriented and walked away from his hospital room at UCSD Medical Center in May
By Steven Luke
NBC 7 San Diego
Sep 15, 2014

California Department of Health and Human Services records obtained by NBC 7 shed new light on what went wrong inside UCSD Medical Center when a disoriented patient walked away from his supervised room into a nearby canyon.

The [May 2013] lapse in hospital security led to a tragic search which ended when ...Thomas Vera’s body was found [several] days later less than a mile from the hospital entrance in Palm Canyon.

Family blames the hospital for allowing 58-year-old Thomas Vera, suffering severe head and neck injuries as well as [delusions], to leave the facility...

According to the CHHS investigation, Vera’s bed alarm never sounded. Vera was under video surveillance, and when nurses were notified, the report states they “attempted to contact security by paging security twice with no response and then pushing the panic button twice with no response.”

The panic button was “broken for 8 days,” according to the report.

State inspectors said the hospital failed to routinely test the buttons and failed to repair them when broken.

Prior to Vera’s disappearance, the most recent test had revealed more than 1 out of every 4 panic buttons at UCSD’s two main hospitals didn’t work.

“That’s incomprehensible to me. This is a big time, generally well thought of medical facility, and it’s like clown school” said legal expert Joel Brant, an attorney who specialized in elder care law.

[Maura Larkins comment: I don't believe they're clowns. The buttons were not a priority. UCSD pays huge amounts of money to maintain the equipment it wants to keep maintained. Were the walkaway patients paying full price? Were they a drain on UCSD financially?]

UC San Diego Health Sciences director of communications Jacqueline Carr released this statement in response to the incident:

“UC San Diego Health System underwent extensive internal and external investigations to identify the reasons that led to this tragic event...”

Fifteen months after the incident, CHHS says no fine or penalty has been issued as a result of the mishap...

Read more here.


Missing Hospital Patient's Body Found in Canyon: Officials
By Monica Garske and Dave Summers
NBCSanDiego
Jun 1, 2013

The body of a missing hospital patient was discovered by search and rescue officials in a canyon Friday evening after an extensive search.

Chula Vista resident Thomas Vera, 58, had been missing since Monday. For the last several weeks, he had been a patient at the UCSD Medical Center.

Vera was admitted to the hospital after falling down the stairs at his home. He suffered a concussion and broken collar bone, according to his family, and was awaiting surgery...

A QUESTION OF PRIORITIES: Profits, Short Staffing, and the Shortchanging of Patient Care at UC Medical Centers

The public sees University of California Medical Centers as premier, world-class facilities. We rely upon them when our loved ones face the most serious illnesses because we expect them to provide the highest level of care. With the UC Medical System earning $6.9 billion in operating revenues and hundreds of millions in profits, it has the resources to do just that.

But recently, patient care advocates have witnessed something else: administrative decisions that prioritize UC’s profit margins over patients’ health. These decisions reflect a shift in values that reached a tipping point with a system-wide policy in 2011 that decentralized UC budget practices, and turned each medical center into an independent profit center.

This culture change is evidenced by a sharp rise in management salaries and compensation, excessive management costs, and unprecedented borrowing to construct new buildings.

Since 2009, management at UC Medical Centers has grown by 38 percent, adding $100 million to the annual payroll cost of management.

Debt service payments have almost quadrupled since 2006.

This diversion of patient care dollars results in management’s need to capture “efficiencies” to bolster profit margins.

While “efficiencies” can be positive, they can also have serious negative consequences. Often taking the form of aggressive cost-cutting measures, some translate into chronic short staffing, over scheduling of operating rooms, prioritizing “VIP” patients over everyone else, shortchanging charity care, and outsourcing essential services.

These degrade the medical centers’ core mission...

The State of California provides significant funding for the University’s Health System. In the fiscal year 2012-2013, it will provide approximately $300 million in public dollars for health sciences instruction....[Read more here.]

Do you want a souvenir DVD of your colonoscopy? So did I.

See all posts re UCSD.

I was scheduled for a routine colonoscopy at UCSD last month.  Nothing controversial about that, right? 

I had had a bizarre experience at Kaiser three years ago when I paid Kaiser $10 for a DVD of the digital video of my VUCG (or "VCUG").  Then suddenly the radiology imaging department claimed that there were no digital images of the procedure--even though the X-rays were done at the brand new Garfield Specialty Center advertised as having all-digital X-rays.  Kaiser said that it only had a few odd thermal paper images of the June 15, 2011 procedure.

So naturally I wanted to make sure that the same thing wouldn't happen at UCSD.  A couple of days before my colonoscopy I called to make sure that I would be able to get a DVD of the procedure.

UCSD's gastroenterology department told me that they don't save any of the digital data generated during colonoscopies.

This is what UCSD claims:

1. The patient can't get a second opinion from any doctor who wasn't watching the computer monitor during the procedure.

2. UCSD is very vulnerable to lawsuits; it can't prove that it wasn't negligent if the patient develops colon cancer that was missed.

3. UCSD can't learn from its mistakes.  It can't go back and see what it was they missed so they can do a better job in the future.

4. A few seconds after the patient leaves, the doctor (and patient) are out of luck if the doctor suddenly thinks, "Hey, what was that I was looking at?  Maybe that was something important.  I'd like to see that again."  Nope.  No chance.   According to UCSD, the images have been flushed from its computers.

5.  UCSD says they don't save the images because it takes up too much space on the hard drive.

Yeah, right.  Digital memory is getting cheaper by the month, so why would UCSD have suddenly stopped saving digital data recently?  They used to give patients DVDs, and before that they gave VHS tapes of colonoscopies.  Those tapes were a lot more expensive and bulky than digital memory.

I asked if I could pay extra to get my procedure saved, but they said NO.  The procedure costs $1300 minimum.  You'd think that would cover a bit of space on the hard drive, wouldn't you?  Well, of course it does.  They just don't want patients to see the images.

These days many doctors in the US are so dead set against patients seeing the images that they sedate everybody, even people who've had colonoscopies before without sedation and didn't have any problem.  They'd rather take the risk of a bad reaction to drugs than to let patients see the video.  I watched doctors on You Tube showing the whole process, and the first thing they asked patients when they woke up was, "Do you remember anything?"  The patients all said NO. 

When I suggested that I didn't believe that UCSD flushed the digital data, UCSD suggested that I go somewhere else if I wanted a DVD.

So I found a doctor who would give me a DVD of my colonoscopy.

The new doctor wants me to get some lab work done, so I went to UCSD today to get blood drawn.

The nurse who drew my blood was very sweet, but it quickly became clear that she had been tasked with finding out who had agreed to give me a DVD of a colonoscopy.  Why would UCSD want to know that?

"Where are you going for your colonoscopy?" she asked.

I didn't want UCSD calling up the doctor and demanding that he not give me a DVD.

"I don't think I should say, since UCSD doesn't approve of patients getting DVDs," I told her.

"Oh, no," she said.  "It's not that.  It's just that we don't do DVDs."

Fine, I thought.  So we're all happy and relaxed about this situation.  I sat back in my chair and the nurse put a pillow on my lap.

"So are you getting it done at a hospital?" she asked.  It seemed that my nurse was not so happy and relaxed about the situation after all.

I didn't want to say YES and I didn't want to say NO.   I didn't want to tell the truth or tell a lie.  So I didn't say anything.  

I was afraid she'd be mad at me and poke me painfully with the needle, but she was very careful. I only felt a tiny pinch.  And then we said friendly good byes.

Message to UCSD: she tried.  She really did try.  But I had planned ahead of time that I wouldn't spill the beans.  So don't blame the very sweet girl who couldn't get the information out of me.

UCSD doctor concealed six-figure pay from medical device company and used that company's products on his patient did nothing wrong; UCSD says he did nothing wrong

Dr. William Taylor, UCSD, implanted screws from a company that paid him a six-figure income and in which he owned hundreds of thousands of dollars in stock options. UCSD paid for his legal defense, saying he did nothing wrong. UCSD paid $1.75 million settlement to avoid trial.

It took longer to uncover some critical details that Dr. William Taylor, the surgeon, had not told the retired special education teacher or the university: He owned stock options worth hundreds of thousands of dollars in the company selling the spinal devices and had also collected six-figure annual fees from the same firm, the lawsuit said. Disclosure of such corporate payments is required by state law and university policy.

A lawyer for UCSD said Taylor did nothing wrong and denied that any patients were harmed. But the university last year paid Kitrosser $1.75 million to settle the case.

Dr. William Taylor got his medical degree from UCLA, whose medical school seems have particular problems with conflicts of interest.

UC system struggles with professors' outside earnings
Failing to report compensation from other sources leads to concerns about conflicts.
BY MELODY PETERSEN
OC Register
May 25, 2014

Doctors eventually solved the mystery of why Brenda Kitrosser suffered from unrelenting pain after her back surgery at a University of California hospital in San Diego.

A UCSD surgeon had implanted experimental screws and other hardware into her back, promising this would relieve her pain. Instead the devices pressed on her nerves endlessly, according to a lawsuit she filed later.

It took longer to uncover some critical details that Dr. William Taylor, the surgeon, had not told the retired special education teacher or the university: He owned stock options worth hundreds of thousands of dollars in the company selling the spinal devices and had also collected six-figure annual fees from the same firm, the lawsuit said. Disclosure of such corporate payments is required by state law and university policy.

A lawyer for UCSD said Taylor did nothing wrong and denied that any patients were harmed. But the university last year paid Kitrosser $1.75 million to settle the case.

The controversy over Taylor’s undisclosed compensation is not an isolated case. The University of California has repeatedly failed to discipline medical professors who did not disclose payments from drugmakers and medical companies.

Last month, after UCLA paid $10 million to settle a lawsuit that centered on undisclosed corporate compensation, the non-profit group Consumer Watchdog called on state Attorney General Kamala Harris to investigate how widespread the unreported payments have become.

In a letter to Harris, the Santa Monica-based consumer group said that evidence presented in the case had shown that the university’s policies were “either inadequate or unenforced.”

“Patients in UC hospitals deserve the most reliable surgical devices and medication,” the group wrote, “and they shouldn’t be treated as subjects in expensive experiments.”

Officials at UCLA and UCI said they have recently increased efforts to make sure professors comply with the rules. UCLA doubled its compliance staff and hired a chief compliance officer. UCI’s chancellor directed all medical faculty to certify they were in compliance with reporting requirements and not engaging in unauthorized outside activities.

Those changes came after a series of undisclosed compensation cases involving professors from across the UC system. In each case, the professors who received the payments were involved in promoting or encouraging the use of a company’s product at the same time they were treating patients. In all the cases except one, it was people from outside the university who discovered the undisclosed payments.

• In a Los Angeles courtroom last month, Dr. Robert Pedowitz, the former chair of UCLA’s orthopedic surgery department, testified that administrators retaliated against him after he tried to get surgeons to report their corporate payments – including one doctor who said he had received $250,000 from a device maker for just 20 days of work. Just before closing arguments, UCLA agreed to pay Pedowitz $10 million to settle the case. The university said administrators did nothing wrong.


Dr. Thomas Ahlering
FILE PHOTO: MARK RIGHTMIRE, ORANGE COUNTY REGISTER

• At UC Irvine, Dr. Thomas Ahlering received more than $100,000 since 2002 from a company selling a surgical robot, but put most of that money in his nonprofit foundation without disclosing it, the Register reported last year. University officials say they have since required Ahlering to turn over $4,000 of that money to the school.

• An investigation by U.S. Sen. Charles Grassley in 2009 found that UCLA spinal surgeon Dr. Jeffrey Wang had failed to report almost a half million dollars in compensation he had received from several companies. UCLA officials say Wang was required to turn over an undisclosed portion of that to the university.

Although some of the professors were required to return a portion of their undisclosed pay to the university, it’s not clear whether the universities disciplined them in any other way.

In Oakland, UC administrators said they have an obligation to encourage faculty to work with companies to develop new medicines and medical devices that can help the public. And they pointed to the policies that the university has long had in place to require faculty to disclose payments.

“We also recognize that more can be done to increase transparency and oversight,” said Steve Montiel, a spokesperson at UC’s Office of the President, “and we are reviewing our policies to determine how best to achieve these goals.”

* * *

Under state law, UC faculty who are leading research must disclose publicly any payments or gifts they receive from the companies or other parties involved in those studies. They must also disclose how much stock or stock options they hold in that company.

According to university policy, all faculty also must disclose on internal annual reports how much time they are spending on outside activities, as well as how much they were paid for that work.