A physician who lacked privileges to perform nephrectomies took out the wrong kidney at a Riverside hospital. A newborn required intubation after receiving IV morphine sulfate intended for the mother in Mission Viejo. And a gero-psychiatric patient suffered a brain bleed and died after his recliner, which lacked crossbars, fell backwards in Poway.
Those three incidents are among 10 that resulted in "immediate jeopardy" to patients, with fines totaling $550,000, in the latest round of penalties against nine California hospitals, state health officials announced yesterday.
Since the law requiring such penalties took effect in January 2007, the state has made 11 announcements of 156 fines totaling $4.8 million against more than 108 hospitals, about one-fourth of the acute care facilities in the state.
Kathleen Billingsley, deputy director for the state's Center for Healthcare Quality, says the publicity about the penalties, unique to California, has helped foster a culture of improving hospital safety.
"These administrative penalties, the press releases that come with them and the publicity results in driving lots of changes," she says. "Every CEO has focused on what they need to do to address these issues, and now, with this 11th release, and they have indicated to me that they don't want to be the hospital that has one of these. They want to be the hospital that solves the problem."
Billingsley adds that she sees hospitals being more transparent about the incidents. "They're talking to the community, saying, ‘Yes, this happened' and they're getting dialogue going to what they're doing to prevent it from happening again. We're starting to see more and more change driven through the hospital community as a result of these."
Money from the fines will be used to conduct studies to find solutions to the most frequently recurring mistakes. One project slated to receive $800,000 will seek ways to avoid surgical teams forgetting to remove tools or sponges during the procedure. Nearly one in five fines issued was due to a retained foreign object, she says.
State law allows public health officials to levy fines between $25,000 for healthcare safety lapses in hospitals that occurred prior to 2009. For those errors since 2009, the penalties are $50,000 for the first violation, $75,000 for the second, and $100,000 for the third or subsequent violation at the same hospital.
The following hospital fines were announced yesterday:
Scripps Green in La Jolla, San Diego County, received two fines, of $50,000 and $75,000. The first resulted because in May 2009, a Scripps physician who was not trained in the use of what was termed a "tricky" lumbar catheter drain, penetrated a patient's spinal column with the wrong end. A 3.5 centimeter tip of the catheter was sheared off during the removal and remained in the patient's ligaments.
The second Scripps fine resulted from the use of equipment between August 1, 2008 and July 31, 2009, potentially exposing 12 surgical hip/fracture patients to blood borne pathogens including HIV and hepatitis. According to the state document, a specialized surgical screwdriver was not disassembled for proper cleaning. Sterile processing department staff "were not aware the sheath came off the screwdriver," according to the state's deficiency report.
Scripps officials issued a one-page statement saying that the patient in the first case was not harmed, but added that it may appeal the second fine, on advice of legal counsel, because the "device manufacturer failed to provide proper in-service education to SPD staff—who were unaware the equipment came apart."
Since 2007, Scripps has received four fines, the second-highest number of financial penalties assessed one hospital.
At Parkview Community Hospital in Riverside, Riverside County, multiple errors resulted in a surgeon performing a radical nephrectomy last July on a patient's right kidney instead of the left. Not only did the doctor not have staff privileges to perform kidney surgery at the time, but the Spanish speaking-patient was not given an opportunity to give full informed consent for the procedure.