Under laws that are the nation's toughest, California on Friday announced 14 penalties totaling $575,000 against 12 hospitals where caregivers put patients in "immediate jeopardy" of harm, such as failing to remove surgical sponges, metal retractors, drill bits, guide wires and a towel.
At a Petaluma hospital, a sponge was not discovered for 1 year and nine months after it was left inside a patient. And at Scripps Memorial in La Jolla, a non-tagged blue towel—used to save an 80-year-old man who was bleeding to death—was not discovered for four months, despite three hospitalizations and a surgery determine why his wound hadn't healed.
Since the laws took effect in 2008 and 2009, 170 fines totaling about $4.8 million have been levied against 112 of the state's 400 hospitals. Of these fines, 39 totaling about $1.2 million are under appeal.
"Information from the incidents that led to these penalties will be used to determine how these deficiencies can be decreased or eliminated over time," said Pam Dickfoss, acting deputy director for the California Department of Public Health. She said the department is working "on multiple fronts with hospitals and patient safety organizations" so hospitals can share safety strategies.
Of the 14 fines, eight were imposed because surgical teams left objects inside patients. In several cases the objects weren't discovered for many months—in one case 21 months—despite patients' complaints of pain.
The funds are to be used for projects that improve patient safety. One $800,000 project will focus on why so many adverse events involve forgotten surgical devices, which state officials say is the second biggest category of immediate jeopardy, accounting for more than 20% of the penalties, state officials said.
"We want California hospitals to be successful in their efforts to reduce hospital acquired infections, decrease medication errors and eliminate surgical error," Dickfoss said.
The amount of fines for each hospital varies depending on when the incident occurred. For those in 2008, fines are $25,000. On Jan. 1, 2009, fines increased to $50,000 for the first violation, $75,000 for the second and $100,000 for third or subsequent violations.
Each hospital has submitted an acceptable plan of correction, state documents said.
California has the toughest immediate jeopardy policy in the nation, says Jill Rosenthal, National Academy for State Health Policy's program director.
Although a few other states allow financial penalties against hospitals, they rarely do, she says.
The latest round of penalties is the state's 12th. The most recent penalties involved these 12 hospitals:
1. California Pacific Medical Center in San Francisco received two fines —$50,000 and $75,000—both for failing to remove foreign objects, a metal retractor and a surgical sponge.
The first incident involved a procedural problem with a sales representative who brought surgical retractor blades into the operating room the day of surgery, after the tool count had been done, rather than 16-24 hours before, state documents said.
As a result, surgeons forgot to remove a retractor blade "lined posteriorly in her thorax" in a patient who underwent mitral valve repair in April of 2009.
A registered nurse interviewed said the surgeon "wanted the retractor and blades immediately. The retractor vendor was in the operating room...When asked if the retractor and blades were counted, she stated 'I eyeballed it, but myself and the circulator didn't get time to count them. I felt pressured and I didn't get time to count....It was a hectic environment, the noise level was very high," state documents said.
The incident was not discovered for two months, when the patient saw her cardiologist in a different state because she was experiencing chest pain. "A subsequent chest x-ray and ultrasound determined the presence of a metal plate in her chest area," which was removed a few days later.
In the second, a sigmoid colon resection patient in July 2009, required readmission and a second surgery to remove the sponge 15 days later. The hospital was penalized for failing to develop a surgical count policy that mandated bagged surgical sponges be recounted. A month after the patient's surgery, he was seen at another facility for recurrent fevers, abdominal pain and gas, and where tests "determined the presence of a retained foreign body in his abdominal cavity."
According to state documents, when a registered nurse interviewed about the incident was "asked if the bagged sponges were recounted during the final count, she responded 'No, we don't open the bags, we just count each bag and assume it contains five sponges,' " State investigators were told that the operating room staff did not use clear bags when bagging the sponges, state documents said.
These were the hospital's second and third penalties.
2. Citrus Valley Medical Center in Covina, Los Angeles County was fined $25,000 for a 2008 incident in which surgeons left a metal piece of a Guidant Heart string device inside an 80-year-old woman undergoing bypass graft procedure. "The patient required a second surgery with general anesthesia to have it removed."
The piece was characterized as "a tube or metallic clip or some other object" from the device and should have been included in the devices that were counted, state documents said. But the hospital incorrectly determined that because it was disposable, it need not be counted.
3. Hanford Community Medical Center, Kings County was fined $25,000 for a 2008 incident in which providers neglected to remove a guide wire from a patient who underwent a breast biopsy and surgery.
After her procedure, the patient described "stabbing pain with shortness of breath when lying down." During several post-operative visits with physicians from January to September, 2009, she was told the pain and subsequent swelling was normal and she was sent to physical therapy.
A massage therapist, on the third visit, "stated the area felt funny" and sent the patient to an outside provider for imaging, which revealed a "retained foreign body object (that) was in three pieces."
4. Kindred Hospital, Westminster, Orange County was fined $25,000 for failing to provide adequate nutrition to prevent, and subsequent failure to manage, a patient's 20 pressure ulcers, which worsened considerably and caused a significant weight loss during four months of stay, according to state documents. Many of the wounds progressed to a point where they were "unstageable."
State documents also said that the patient was observed lying on a pressure-relieving air mattress that family members "stated sometimes the mattress did not function, the mattress would become flat."
5. Palomar Medical Center, Escondido, San Diego County was fined $50,000 after a patient fell out of bed, became disconnected from her cardiac monitor, and was "on the floor in this condition for more than an hour before ICU staff found her" and subsequently died.
State documents say the hospital failed to observe state mandated nurse-patient staff ratios of one-to-two and instead had ratios of one-to-five.
"The failure of the ICU staff to monitor, assess and intervene on behalf of patient A resulted in the patient suffering prolonged cardiac arrest, severe brain injury, progressive organ failure, and ultimately, the withdrawal of life support."
6. Petaluma Valley Hospital, Sonoma County was fined $50,000 for allowing a mechanically ventilated patient to develop an unstageable pressure ulcer inside the left upper lip due to mismanagement of an endotracheal tube placement, state documents said.
The hospital also left a lap sponge inside a different patient's body cavity, which was not removed for 1 year and nine months, "placing the patient at increased risk for complications due to the additional surgery and anesthesia."
After the January, 2008 surgery, when the patient complained about abdominal pain, a physician ordered a complete abdominal x-ray series, but it was cancelled. He came to the emergency department on Sept. 28, 2009 in "severe abdominal pain" and said that he had nausea and vomited after eating solid food.
"The surgeon stated that he could not really explain how it happened, except that one of the lap sponges used to retract the bowel was hidden...even though the sponge count was documented as being correct."
7. Placentia Linda Hospital, Orange County was fined $25,000 when a total right knee component was used to replace a patient's left knee, and because the surgical team did not properly engage in typical "time out" procedures prior to surgery, when the error may have been caught. The surgery resulted in the patient enduring considerable pain, and a second surgery to insert the correct knee, state documents say.
8. Scripps Memorial Hospital in La Jolla, San Diego County was fined $50,000 for not counting one of several untagged blue towels, which remained in a patient's abdominal cavity for four months "during which time Patient A was hospitalized three times for treatment related to non-healing post surgery," and despite several CT scans to locate the cause, according to state documents.
The 80-year old man had come to the emergency department in December, 2009 from a skilled nursing facility and was diagnosed with "an acute gastrointestinal bleed and hypovolemic (low blood volume) shock." He was bleeding so much, according to the state report, the surgeon said that when he opened the patient's abdomen "there was so much blood that he was 'trying to scoop it out with my hands.' "
To locate the source of the bleeding, he told the scrub technician to "get me towels," according to the report. "It took several towels to staunch the flow."
The report said the physician told state investigators that when surgery in April finally discovered the towel "the team was devastated...The patient was dying. It was an uncontrolled environment," and "we used what was available to save a life."
Blue towels were not supposed to be used, the report said, "but there were no radiopaque towels that can be seen with an x-ray immediately available."
This was the hospital's fourth penalty.
9. Southwest Healthcare System, Murrieta, Riverside County was fined $25,000 for failing to remove a 10-inch by 2-inch metal retractor from a woman who was admitted with uterine contractions in 2008.
According to the state's report, the hospital's practice was to count instruments prior to closing the surgical wound, but "once the wound is closed a sponge count is done, but not an instrument (count)."
Southwest has received seven penalties so far, more than any other hospital in the state, and has been fighting federal and state efforts to take away its license and ability to receive reimbursement after numerous violations.
Earlier this year, Kathleen Billingsley, then CDPH deputy director.
said violations at the hospital "constitute conduct inimical to the public health, morals, welfare and safety." The hospital is now under a settlement agreement in which it is engaged in major improvement efforts.
11. The University of California San Francisco Medical Center received two fines, each $25,000, for failing to remove a piece of a drill bit used during surgery to remove a patient's brain tumor, and for administering a high-risk blood-thinning drug to an infant at a dose that was 10 times too high.
In the first incident, surgical staff told state investigators that they were aware that a surgical drill bit "was missing prior to the patient leaving the operating room but failed to obtain an x-ray as required."
Two days later, an MRI showed "a large signal void is present over the left frontal lobe as a result of a metallic artifact arising from a retained drill bit in the left frontal bone."
The surgeon involved in the case said he "the surgical technician had noticed that the tip of the drill bit was broken and had brought it to his attention. He stated he inspected the wound twice but was unable to locate a missing drill bit. He said 'it's my responsibility. I should have asked for an x-ray.' "
In the second incident, according to state documents, the hospital's "satellite pharmacy erroneously prepared three syringes of .2 ml of Enoxaparin 100mg/ml (each syringe contained 20 mg instead of 2 mg of Enoxaparin, 20 times the prescribed dose)." After the dose was detected a day later, an antidote was administered twice to reverse the drug's effect.
The hospital had not had protocols or guidelines on the drug's preparation for neonatal and pediatric patients, according to state documents.
This is UCSF's third and fourth administrative penalty.
11. USC University Hospital in Los Angeles was fined $50,000 for administering an incorrect dose of a medication highly toxic to the kidneys for a patient with cystic fibrosis. Instead of a 100 mg dose of the drug Colistin, to treat an infection, she was given 150 mg.
According to state documents, the failure resulted in the patient developing kidney failure, a seizure, encephalopathy and requiring continuous kidney replacement therapy for 70 hour and dialysis.
A nurse who was supposed to check the dosage for the patient "stated she was 'busy and doing many things,' " according to the state report. "She signed the physician's order indicating that Colistin was verified for dosage accuracy...however (she) cannot recall verifying the Colistin dosage."
12. Western Medical Center, Santa Ana, Orange County was fined $75,000 for administering possibly defective vaccines to 1,636 newborn babies and five newborns born to mothers who were carriers of hepatitis B, according to the state report.
The vaccines included inoculums for hepatitis, rabies, DTP, MMR and hepatitis B, rota-virus, polio, pneumococcal, meningococcal and varicella xoster. had been stored in a refrigerator whose temperatures were recorded at below freezing, and as low as minus 3.7 Centigrade.
This is the third penalty against Western.
Penalties issued by the California Public Health Department may be viewed by county here.
See Also:
Top 10 Most Costly, Frequent Medical Errors
Nine More Hospitals Fined $550,000 for Putting Patients at Risk
Southwest Healthcare: How Could So Much Be So Wrong?
7 Hospitals Fined for Immediate Jeopardy Mistakes
California Hospitals Fined for Alleged Immediate Jeopardy Mistakes
Hospitals Fined for Forgotten Surgical Devices, Wrong Surgeries, Burnt Patient
12 More Hospitals Fined For Putting Patients In Immediate Jeopardy
Immediate Jeopardy: Words No Hospital Official Wants to Hear