Lucile Packard Children’s Hospital was fined $25,000 last week by the California Department of Public Health for failing to have correct policies in place regarding the use of ventilators and gases, which the state concluded put a patient in danger.

The hospital self-reported the error to the state, which then levied the fine despite disagreements with hospital officials about the error.

A report provided to The Daily by the health department cites the hospital for failing to follow its policy on the storage of ventilator equipment and neglecting to have diagrams illustrating the setup of nitrogen gas for the ventilator.

“There was an incorrect configuration of the ventilatory equipment at a patient’s bedside, and this error was immediately recognized and corrected,” said Christy Sandborg, the hospital’s chief of staff. “There was no harm done to the patient.”

The health department report said the patient, a nine-day old infant, had his heart rate drop to 62 beats per minute — well below the normal newborn range of 100 to 160 — as a result of the ventilator error. He had to be manually ventilated five times.

“We self-reported the error because we think that we have a commitment to patient safety,” Sandborg said. “The state defines this as a danger to the patient. We actually disagree, and we went to the state and discussed it with them, and they didn’t change their opinion.”

Sandborg disagrees with the fine because hospital policies ensured that the patient was not harmed by the error.

“Because we were immediately at the bedside, we didn’t allow harm to come to the patient,” Sandborg said. “The patient is doing well and recovering.”

The hospital is now taking steps to make sure that such an incident does not happen again.

“We’ve never had this issue happen before,” Sandborg said. “We actually ensure that the instructions are available, and our policy is to be at the bedside when this sort of thing is being set up, so we would recognize if there was an error in the configuration.”