A 29-year-old patient who entered a Kaiser Foundation hospital in Oakland to have a facial birthmark removed died of an arterial embolism because her doctor didn't read the operating instructions for the laser device he tried to use.
A patient admitted to a Sutter hospital in Crescent City to remove a basal cell carcinoma suffered burns on her face, chest, and ear when the surgeon let the oxygen mask on her face get too close to a cautery device, which started a fire.
And at a Kaiser Foundation hospital in San Diego, a surgeon removed the wrong kidney in an 85-year-old man. The surgeon told investigators that he did not have radiology images in the operating suite because he "did not feel" they "were relevant to this case."
These departures from safe practice, all of which occurred in 2010 or 2011, are among 12 incidents warranting "immediate jeopardy" penalties, which California health officials levied Thursday to 10 hospitals. Two hospitals received penalties for two such incidents. In all, four patients died from these errors and several others were seriously hurt.
California law established in 2007 calls for such hospitals to be penalized with fines of $50,000, $75,000 or $100,000, depending on the frequency of violations. Fines against small, rural hospitals may be lower.
The penalties are designed to prompt hospitals "to be successful in their efforts to reduce hospital-acquired infections, decrease medication errors, eliminate surgical errors, and prevent other adverse events," Debby Rogers, deputy director of the Center for Health Care Quality for the California Department of Public Health, said during a news briefing to announce the latest $785,000 worth of fines.
"The value of the fines is in bringing awareness both to the healthcare industry and healthcare providers, but also to consumers and patients who can then take this information to have a conversation with their healthcare providers, to better understand the safeguards that each facility and each provider would put into place to prevent these types of events," she said.