State Rebukes UCSD Medical Center for Giving Boy, 3, Fatal Medication

UC San Diego Medical Center has been cited for violating state hospital licensing rules last July when a technician there gave a 3-year-old boy a sedative that led to his death.

Not only was the technician unauthorized to give medication to patients, a state report says, but she also failed to record basic information about the incident in the boy’s medical record.

The technician was authorized to perform heart tests called echocardiograms and is licensed as a physician in Mexico, but not California.

The Tijuana boy was a patient in the UCSD pediatric cardiology program, which has been under investigation since August on suspicion of defrauding Medi-Cal of up to $1 million by helping Mexicans to cross the border and qualify for state-paid cardiac care.

Negotiations between Medi-Cal officials and UCSD are continuing. A settlement could come within the next two weeks, said Larry Malm, an investigator for the state Department of Health Services.

It was during the Medi-Cal fraud investigation that the 3-year-old’s death on July 10 came to light.

The boy went to the outpatient pediatric cardiology clinic at UCSD because of congenital heart disease and subsequent lung problems, according to the state report completed last month.

Shortly after the boy’s arrival in the early afternoon, an unidentified attending physician gave a telephone order for the boy to receive the sedative chloral hydrate before the ultrasound imaging of his heart, or echocardiogram.

The technician “drew up the prescribed oral sedative and gave it to the mother to administer,” the report says.

“Twenty minutes after receiving the chloral hydrate, the child suffered respiratory arrest which progressed to cardiac arrest. Resuscitation efforts continued for one hour and 20 minutes,” it says.

The report quotes a San Diego medical examiner’s report on the boy’s death as saying: “It is my opinion that death was primarily a result of the natural heart and lung disease, but that the effects of the disease were exacerbated by the sedative. Because of the contribution of the medication, the manner of death is an accident.”

The state investigator’s review of the boy’s medical records showed that it contained no record of his medical history or previous treatment for his heart problems.

Neither was there any notation about the medication order made by a nurse, physician’s assistant or pharmacist, as required by UCSD’s own procedural rules.

The citations by the licensing and certification division of the state health department were issued Dec. 28 after an investigation that began in October.

As is routine in such procedural violations, the citations resulted primarily in paperwork.

UCSD responded to the citations Jan. 2 with a plan to correct the violations by training and monitoring employees better; the remedies are to be complete by Jan. 27.

Hospital spokeswoman Leslie Franz said Tuesday that UCSD has already corrected the violations found by the state. The investigator’s findings were similar to those found by an internal UCSD inquiry, she said.

UCSD will not be specific about its response to the death or to the allegations of Medi-Cal fraud within the pediatric cardiology program. However, Dr. David J. Sahn was replaced last fall as chairman as a result of the problems. He remains a professor in the department.

One cardiologist known to be at the center of the investigation since last March is Dr. Lilliam M. Valdes-Cruz, an associate professor.