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Errors range from dropped baby to a lost patient
This is an archived article that was published on sltrib.com in 2008, and information in the article may be outdated. It is provided only for personal research purposes and may not be reprinted.

Examples of "never events," the most serious medical errors, and other patient safety problems found in reports of Utah hospital violations of health and safety codes.

Dropped baby: Last August, a 10-day-old was dropped on her head as two nurses aides at Sanpete Valley Hospital placed her in a carrier. The mother, who wasn't in the room, wasn't told. She returned to the hospital after finding a lump on her baby's head.

She ended up at two other hospitals, where she was suspected of abuse. The aides "confessed" after Sanpete was contacted. A CT scan revealed a fracture and bleeding, and the mother was told her baby would have severe headaches for several weeks.

The hospital's correction plan included training employees. Owner Intermountain Healthcare also now requires parents to take children in and out of carriers.

Therapy burns. In 2003, a mentally-impaired 23-year-old suffered a second-degree burn from moist hot packs placed on her knee during physical therapy at American Fork Hospital.

Jason Mathis, spokesman for Intermountain Healthcare, declined to discuss specifics due to privacy concerns. "We care for patients in 5 to 6 million visits every year at hospitals and clinics. Sentinel events occur in only a few," he noted. "Our goal is zero, but it is a difficult goal to achieve."

Neglected woman. Timpanogos Regional Hospital in Orem was cited by the state this year after an 88-year-old woman developed a serious bed sore on her tailbone because she wasn't frequently repositioned. The wound required care at another hospital and a long-term care facility.

Owner Mountain Star said it "deeply regrets" the patient "may have experienced anything less than excellent care."

Lost patient. The state cited University of Utah Hospital in 2006 after a "vulnerable" man thought to have "psychotic behaviors" disappeared during care for a wrist fracture. Almost 14 hours later, campus police found him sleeping outside. The hospital had not notified his nursing home or police.

In a statement, the U. said such adverse events are rare, but are taken "very seriously and thoroughly review[ed.]"

"As long as there are these types of cases, hospitals have plenty of room for improvement," said Kelly Criddle, who inspects Utah hospitals and ambulatory surgical centers. "That said, I believe we do have high-quality health care provided by hospitals in this state."

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