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Immediate Jeopardy: 14 CA Hospitals Fined $850,000

Cheryl Clark, for HealthLeaders Media, December 12, 2011

Another 14 California hospitals have been ordered to pay fines totaling $850,000 in the latest round of medical errors involving immediate jeopardy to patients, state health officials said last week.

These incidents include seven retained foreign objects, including a 2.5 cm temporary pin used in a woman's spine surgery. The pin apparently became dislodged and was not discovered until it began to impinge on her airway, impeding her ability to breathe.

Other forgotten surgical materials included an 8 x 5 mm metal screw cap, which was part of a breakaway portion on implanted hardware; a surgical towel; and four laparotomy sponges, including one that went undiscovered for eight months, causing chronic infections and rehospitalizations.

Other incidents that placed patients in immediate jeopardy of harm or death included a "Code Pink," in which a newborn was abducted from a labor and delivery unit despite the use of a bracelet designed to signal an alarm if an infant is taken from the area; a morphine overdose which resulted in a patient's death; and the administration of "compromised" medications and vaccines, which were incorrectly refrigerated to freezing temperatures, to an estimated 5,000 patients.

Under California state laws, penalties are assessed at $25,000 if the incident occurred prior to 2009, but after 2009 the amount is raised to $50,000 for the first violation, $75,000 for the second, and $100,000 for the third or subsequent penalty.

Two of the hospitals that received these administrative penalties, Scripps Memorial Hospital in La Jolla and Mission Hospital Regional Medical Center in Mission Viejo, received the maximum fine of $100,000 because they had more than two prior penalties since the beginning of 2009. In this round, Scripps received its sixth penalty and Mission its fourth.

Since the state law allowing financial penalties for immediate jeopardy incidents took effect in 2007, nearly one in four California hospitals, or about 125, have been ordered to pay 214 financial penalties totaling nearly $7.7 million. About $5.1 million of that has been collected, according to California Department of Public Health spokesman Ralph Montano. Several hospitals are appealing portions of the remainder.

According to state documents, which can be found on the state website by county, these are some details of each incident:

1. At Fresno Surgical Hospital in Fresno County, surgeons failed to remove a lap sponge in a patient who continued to have infections after her discharge for eight months. "Patient 1 stated her physician continued to place her on antibiotics (Cipro, Levaquin) for about 3-4 months making changes of the type of antibiotics until she collapsed at home and was admitted into a hospital for 11 days to be treated with IV antibiotics for infection," according to the state's report.

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