Skip to main content

CA Fines 10 Hospitals $625,000 for Medical Errors

 |  By cclark@healthleadersmedia.com  
   June 07, 2013

Retained surgical objects, patient falls, and medication errors are the top violations leading to immediate jeopardy penalties issued to hospitals by the California Department of Health.

Five patients had to undergo repeat surgeries to retrieve forgotten surgical items such as a sponge, a retractor, and a clamp; two patients died after falls; and three patients suffered harm because of medication errors, according to Thursday's release of immediate jeopardy penalties against 10 California hospitals.

"In issuing these administrative penalties, our goal at the Department of Public Health is to improve the quality of healthcare at all California hospitals," Debby Rogers, deputy director of the Center for Health Care Quality, said during a teleconference.  

"Information about the incidents that led to these penalties can be used to determine how these violations or deficiencies can be decreased and eliminated over time," she said.  

Under state law that has been in effect since 2009, California health officials publicize such incidents because they show that hospitals have failed to comply with requirements of licensure, and those failures have caused or were likely to cause serious injury or death to a patient.

The amounts of the fines vary depending on whether the violation is a hospital's first, second, third, or subsequent, and range from $25,000 to $100,000 each. In this latest round, state regulatory officials assessed a total of $625,000, bringing the total to $11 million dollars in penalties that 150 of the state's 400 hospitals have been told to pay.  

About $8.8 million of that has been collected, while a portion of the rest is under appeal, Rogers said. Some of the money is being used on developing improvement projects for some of the most common immediate jeopardy mistakes, such as retained foreign surgical objects and medication errors, Rogers said.

Details of the incidents as shown on state documents, which can be found on the state website by county along with each hospital's required plans of correction, are as follows:

Retained surgical objects

1. At Simi Valley Hospital & Health Care Services, Simi Valley, in Ventura County, failed to remove an 8-inch Babcock clamp (a device used to grasp, join, compress, or support an organ, tissue or vessel), from a patient who had abdominal surgery. After the patient complained of "significant pain and experienced increased bile drainage, a series of abdominal X-rays revealed a clamp.  

After he underwent a second surgery to remove the device, he endured "sudden, swift bleeding" from his spleen, requiring an emergency splenectomy.  

State investigators faulted the hospital for having "no documentation in the medical record to indicate when the counts were completed."  

"Patients in whom a surgical instrument is left after abdominal surgery are at high risk for serious complications, including pain, perforation, and infection," but the facility's "failure to ensure that the instrument count was correct…created a situation that was likely to cause serious injury or death to the patient."

Penalty: $50,000. This is the hospital's second penalty.

2. At California Pacific Medical Center, Pacific Campus, in San Francisco County, providers failed to implement a surgical count policy to track sponges used for packing a wound. This resulted in a patient who underwent bladder surgery being discharged with a retained sponge.

A routine post-operative test indicated a possible retained sponge, which was confirmed by a pelvic CT that found not only the sponge but also "a large associated presumed abscess cavity," which had to be removed during a second surgery.

When asked to explain how the staff could have followed the policy, "and a sponge was still left" in the patient, the senior director of surgical services replied, "the staff made a mistake in counting" and added that there "was difficulty in getting all the sponges in the counter bags for the final count and that the policy in effect at the time of the retained sponge did not require all sponges be in the counter bags for the final count."

Penalty: $100,000. This is the hospital's fourth penalty.

3. At St. Joseph Hospital in Eureka, in Humboldt County, the surgical team forgot to remove a "linear metallic flat object" that turned out to be a visceral retractor from the abdomen of a patient who underwent hernia surgery.

The device, which goes by the brand name of FISH because of its resemblance, was said to be "a baby blue colored, flat vinyl object shaped like a flounder measuring 10 inches in length and 6.5 inches at the widest section. /The surgeon was supposed to have removed the FISH with its attached loop and string, "and pull it out through a small opening" that would then be sewn shut.

The patient went home, but "her postoperative pain level did not decrease as expected. After monitoring the patient's pain for two months, Surgeon A stated that he ordered a CT scan of the abdomen which identified that there was a foreign object in the patient. When he viewed the CT scan, he realized that the 'FISH' was still in the patient."

Penalty: $50,000. This is the hospital's first penalty.

4. At California Pacific Medical Center, St. Luke's Campus, San Francisco, an attempt to treat a patient undergoing emergent dialysis resulted in providers neglecting to remove a catheter guide wire that had been inserted in the right femoral vein, but had migrated to his right ventricle.

But after the patient developed critical symptoms and was moved to the ICU, "it was noted that he was very tachypneic (rapid breathing), had altered mental status, had bradycardic arrest (arrhythmia or abnormally slow heart beat less than 50 beats per minute) short CPR, apparently difficult intubation.

A chest x-ray post intubation "noted that he had something that looked like a guide wire at the level of his right ventricle," where it "could have traveled in the direction of blood flow from femoral vein."

The patient had to undergo a second procedure to retrieve the guide wire from the vena cava.

Subsequently, the physician who had placed the guidewire told investigators that he "wasn't familiar" with that particular cath kit, and "I thought I knew how to use it."

Penalty: $50,000. This is the hospital's first penalty.

5. At UCLA Medical Center and Orthopaedic Hospital, Santa Monica, in Los Angeles County, surgeons neglected to remove a sponge from a patient who had to undergo a second surgery to remove it.

State investigators said that in having to undergo another procedure with anesthesia, the patient "was placed at risk for possible additional complications (i.e. bleeding, infection, shock, adhesions, ileus (paralysis of the bowel), changes in blood pressure, heart rate or heart rhythm and allergic reaction to general anesthetic medicine."

Penalty: $50,000. This is the hospital's first penalty.

Falls

6. At Tri-City Medical Center, Oceanside, San Diego County, providers failed to follow procedures prevent a patient known to be at risk of falls from falling out of his geri/bed chair in the hallway where he waited for a radiology scan.  

He suffered a blunt force injury of his torso, rib fractures, and a hemoperitoneum (blood in is peritoneal cavity and hemorrhage, which led to his death hours later.  

State investigators said that while most geri/bed chairs are equipped with a strap to prevent falls, this one did not.  

After he fell, however, a physician's assistant, who noticed him having a hard time breathing did not call a physician.  

The patient also complained of chest and shoulder pain, and had bruising on his chest. An autopsy requested by the family found that the patient had "rib fractures, hemoperitoneum, and retroperitoneal hemorrhage due to blunt force injury of torso" with a contributing factor of advanced metastatic prostate cancer.  

Penalty: $75,000. This is the hospital's third penalty.

7. At Palomar Health, Downtown Campus, Escondido, in San Diego County, providers failed to prevent a patient from falling and fatally injuring his head in the intermediate care unit. "The fall resulted in bleeding in the brain, coma, and eventual withdrawal of life support and ultimately the death of Patient A," state investigators wrote.

According to the report, the patient had shown signs of alcohol withdrawal, and although seizure and fall precautions were ordered, staff did not prevent him from getting out of bed.

According to a nurse who witnessed the patient, "he took the entire tab alarm (a device connected to the patient's clothing and bed that emits a loud noise when it becomes detached) unit with him so that the alarm would not disconnect from his person, and therefore, no alarm would sound."

Just prior to the patient's fall, he demonstrated to a nurse assigned to his care that "he knew how to take the bed alarm off without the alarm sounding." After leaving the room, caregivers "heard a loud 'thud' " and the patient was bleeding from his head and his nose, later diagnosed as a subdural hematoma. He later died.

Penalty: $100,000. This is the hospital's third penalty.

Medication errors

8. At Marin General Hospital, Greenbrae, in Marin County, staff administered an anti-hypertension medication, Labetalol, to a patient with sepsis instead of Ceftriaxone, the prescribed antibiotic, "which resulted in renal failure and dry gangrene of all ten toes and two fingers, and contributed to (the patient's) death," investigators wrote.

According to the report, a licensed nurse "had pulled the incorrect medication from the Automated Drug Cabinet" resulting in a long period of low blood pressure, ischemic hepatitis, and impending gangrene.

The patient also developed confusion, poor attention and concentration, "likely due to the lack of oxygen he sustained, and also due to the build-up of toxic elements due to kidney failure and shock liver."

According to physician progress notes, the patient "expressed the wish to just go to sleep. Faced with a lifetime of continued dialysis, and with increasing pain from gangrenous toes and fingers (the patient) and his family decided to stop all treatment. (The patient) died.

Investigators wrote that bottles of the two drugs "were seen to be approximately the same size," although Labetalol was a liquid and the Ceftriaxone was a powder," and one was blue and the other pink.

Penalty is $75,000. This is the hospital's third penalty.

9. At Children's Hospital of Los Angeles, in Los Angeles County, a physician erroneously ordered a dose of amphotericin B that was three times higher than the maximum dosage for a child admitted for a bone marrow transplant to treat acute myeloblastic leukemia and a fungal infection in the lung.

"The pharmacy staff failed to notice failed to recognize the dosing irregularity and the administering nurse failed to verify safe dose calculation."

The patient "subsequently experienced a cardiac arrest and expired."

According to the investigators' report, the bone marrow specialist on the patient's care team said the doctor had intended to order a different drug, Ambisome, but said physicians "often refer to Ambisome as amphotericin B" but which has a different form.

Penalty is $50,000. This is the hospital's first penalty.

10. At Fallbrook Hospital, Fallbrook, in San Diego County obstetric/newborn nursery staff failed to safely deliver medication related to the delivery of an infant following delivery.

As a result, the newborn received an injection of Methergine, a drug used to prevent and control postpartum hemorrhage in mothers following delivery, that was intended for the baby's mother.

The staff "further failed to intervene or advocate for the patients (in) reporting the medication error to the baby's or the mother's physician in a timely manner," which resulted in the baby developing seizures, being intubated, and requiring emergency transfer to another hospital, and multiple tests and treatments for seizures for some time.

According to the physician's report, the baby "will require further neurological examinations due to ischemic injuries (damage or death to brain tissue) seen on an MRI of the brain.)

The staff also failed to promptly notify a physician that a serious medication had occurred. "According to Physician X, he wasn't notified that anything had gone wrong until he came in the next day. Physician X stated that he would have expected to be notified right away" and if he had been, "he would have taken action immediately and called a pediatrician.

Penalty: $25,000. This is the hospital's first penalty.

Tagged Under:


Get the latest on healthcare leadership in your inbox.