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California Hospitals Fined for Alleged Immediate Jeopardy Mistakes

Cheryl Clark, for HealthLeaders Media, January 28, 2010

California health officials fined 13 hospitals a total of $650,000 Wednesday for 16 "immediate jeopardy" medical mistakes that caused or could have caused patient harm, including at least three that may have led to patient deaths.

"In issuing these administrative penalties, our goal . . . is to improve the quality of healthcare at all California hospitals," said Kathleen Billingsley, deputy director of the California Department of Public Health. "We want California hospitals to be successful in their efforts to reduce hospital acquired infections, decrease medical errors and eliminate surgical errors."

Billingsley said that money from the penalties eventually will be used on projects "to determine how these violations or deficiencies can be decreased and eliminated over time."

This brings the total number of "immediate jeopardy" penalties to 134 filed against 90 facilities since a law allowing monetary fines took effect Jan. 1 2007, with a total of $3.675 million assessed so far. Of that amount, $2.3 million has been collected, Billingsley said. She has issued announcements of earlier fines on eight prior occasions.

Of the 134 fines, 22 of them are currently under appeal or in litigation, she said.

The state assesses hospitals fines of $25,000 if the medical error occurred in 2007 or 2008. In 2009, the amount rose to $50,000 for the first violation, $75,000 for the second, and $100,000 for the third or subsequent violation.

Most of the hospital errors in this round of announced fines occurred in 2009, although several occurred in 2008.

Asked why there is such a delay in announcing the penalties, California Department of Public Health spokesman Ralph Montano explained "every administrative penalty has to go through a review process. Some take longer than others. We do a thorough job. When it is completed it is released."

The incidents announced Wednesday were:

1. At Hoag Memorial Hospital Presbyterian in Newport Beach, a metal wheelchair gurney was brought into a room housing an MRI machine, which was against hospital policy. When the MRI was turned on, the gurney was drawn in by the magnetic force, crushing the left lower extremity of a patient undergoing treatment, state investigators said in their report. This is Hoag's third fine.

2. Unnoticed by the operating room team at Sharp Grossmont Hospital in San Diego, a surgeon marked and removed the wrong side of the skull of a 93-year-old man undergoing surgery during repair of a bleed in his brain. As a result, the other side of his skull bone had to be removed for a second surgery, requiring a longer period of anesthesia. This is the second fine for Grossmont.

"The entire surgical team failed to ensure that the correct surgical side was operated on," state investigators said in their report.

3. John F. Kennedy Memorial Hospital in Indio received four penalties totaling $100,000 for incidents in 2008 involving the use of nurses who weren't trained or certified to perform emergency room tasks. State investigators documented the problems in four reports, one of which implicated the facility for failing to ensure nursing clinical competency in the death of a two-year old boy.

The infant remained in the emergency room instead of being transferred to the neonatal intensive care unit, prompting the director of the ED to tell state officials: "That baby didn't have to die," according to the state report.

"The employee file for RN 1 . . . indicated RN 1 was hired by the facility on July 7, 2008 (three and a half weeks prior to being assigned to this critical baby)," the report said. "The file indicated RN 1 did not have PALS (Pediatric Advanced Life Support) certification or validation of ED clinical competencies."

4. At Santa Clara Valley Medical Center in San Jose, emergency room staff failed to accurately diagnose a patient with a hemoglobin count below half of what is normal. "RN A stated that if he had been aware the patient's hemoglobin was 6.1 he would have assessed him as a level 2 acuity, which would have changed the priority for the patient to immediately be medically screened by the physician when the next room was available. As a level 3, the patient had to wait until the urgent cases had been seen," investigators wrote.

"The patient was in the ED waiting room for approximately seven hours with a medical emergency condition without a medical screening examination by a physician, which could cause or likely cause death."

The patient was later "found in the lobby unconscious and a code blue cardiopulmonary resuscitation was started . . . The resuscitation was unsuccessful and the patient expired."

5. At St. Jude Medical Center in Fullerton, several emergency room systems intended to monitor patients in cardiac distress failed to work to alert staff of changes in a patient's heart rate, such as an audible alarm and a visual alarm. When the patient's cardiac monitor showed "0" indicating no heart rhythm, "the nurse stated she thought the monitor leads must have come off," according to the state.

"She stated she could see the patient sitting upright on the gurney and thought the patient was alright. She did not go over and check the patient ... The Clinical Clerical Technician walked by the patient, noticed something was wrong with the patient, called the physician and a Code Blue (cardiac resuscitation) was started."

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