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Adverse Events Draw $775K in Fines at 9 CA Hospitals

Cheryl Clark, for HealthLeaders Media, October 28, 2013

The most recent round of administrative penalties for hospital deficiencies constituting immediate jeopardy includes two patient falls resulting in deaths, a wrong-site surgery, and a retained surgical object.


Medical Errors


>>>Slideshow: CA hospitals penalized
for medical errors

At Sharp Memorial Hospital in San Diego, a surgical team took out a man's healthy left kidney instead of his cancerous right one because the hospital didn't make imaging studies viewable in the operating room and because the surgeon "forgot" how to log-in to see them before cutting into the patient.

At Antelope Valley Hospital in Lancaster, a patient returned to the emergency department three times before doctors realized they had forgotten to remove a 9 x 6-inch surgical device. According to state officials, the device was not included in the instrument count.

And at Community Regional Medical Center in Fresno, a surgeon left the OR after instructing a physician's assistant to finish the surgery, which the assistant was not trained to complete. The patient suffered major blood loss, cardiac arrest, and loss of oxygen to the brain. At the completion of a state investigation, the patient remained on life support.

These major adverse events in California hospitals are among 10 detailed in state documents accompanying $775,000 in administrative penalties to these hospitals, which state officials announced last week. The fines are assessed once state investigators determine that lapses in regulatory compliance caused or likely caused serious injury or death to a patient.

Since these penalties began in 2007, the state had issued 295 penalties to more than 155 of the state's 400 acute care facilities, according to a statement issued Thursday by the California Department of Public Health.

Including the latest round of penalties, the state has assessed $13.3 million in fines and has collected $10.1 million. Most of the $3.2 million not yet collected is under appeal by the hospitals that dispute the state's findings.

The funds are to be used for programs to improve healthcare safety.

In a phone interview Thursday, Debby Rogers, deputy director for the state Department of Public Health's Center for Healthcare Quality, refused to comment on any particular hospital's harmful event, but acknowledged that some incidents are more serious than others.

New regulations due to take effect by the end of the year, will allow the state to consider how much patient harm was done "and how widespread inside the hospital a particularly deficiency is."

"We feel strongly that publicizing these deficiencies helps hold these facilities accountable but it also empowers consumers to speak to their providers to put protections in place so something like this doesn't happen," Rogers said.

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