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Medical Errors Draw Fines for 7 CA Hospitals

 |  By cclark@healthleadersmedia.com  
   February 07, 2013

A patient admitted for bladder stone removal surgery died after a Modesto physician failed to call a Code Blue and refused suggestions from three colleagues that he should re-intubate when the patient stopped breathing, Asked later why he delayed taking action, he told state investigators, "I zoned out."

A second hospitalized patient was sexually assaulted by an Orange County physician after hospital staff failed to report the doctor's behavior when they witnessed his first assault on a female patient under anesthesia. 

And a San Francisco patient died during a procedure when the anesthesiologist failed to monitor respiratory status after administering the drug Versed.

These three immediate jeopardy findings are among 10 announced Wednesday by California Department of Public Health, which fined three facilities $50,000, three facilities $75,000 and four facilities $100,000 for causing patient harm. Three of the hospitals received two penalties each.

Debby Rogers, deputy director for the California Department of Public Health, said that since the law requiring such hospital penalties took effect in 2007, her department has assessed 264 immediate jeopardy penalties totaling $10.4 million against 142 hospitals, and has collected $8.2 million. 

A regulation under review would increase the fine amounts by $25,000 each, so the penalty for the first incident would be $75,000, the second $100,000 and the third or subsequent immediate jeopardy event $125,000. Incidents occurring prior to 2009 brought fines of $25,000 each.

Also in the works are regulations that would enable the department to administer penalties for other problematic incidents in hospital care that did not result in the potential for or actual serious harm or death to a patient.

"We want California hospitals to be successful in their efforts to reduce hospital acquired infections , decrease mediation errors, eliminate surgical errors and prevent  other adverse events," she said during a news briefing.

She added that UCSF now ties with Southwest Healthcare System in Riverside, CA for having eight penalties, more than other hospitals in the state.

The details of each incident, including each hospital's detailed plan of correction, are as follows, according to documents posted here by county:

1. At Adventist Medical Center in Hanford, in Kings County, a patient admitted for surgical repair of the right heel to decrease arthritic pain died shortly after the procedure because the Patient Controlled Analgesia (PCA) unit, through which he could self-administer morphine, lacked limits to prevent him from overdosing, state documents said.

"The Director of Pharmacy (DOP) stated Patient 1's morphine order was at the upper end of the dosing scale and that there was no documentation opioid tolerance was considered.

The DOP stated "...in my opinion, they (the Pharmacist) should have caught this; it was an unusually large dose...." The DOP  agreed that the facility did not have a policy and procedure for the safe use of PCA devices.

According to guidelines developed for safe use of PCA devices, PCA errors "represent a four-fold higher risk than other reported medication errors," and "Every clinician and hospital environment has a PCA (error) story."

The penalty is $50,000. This is Adventist's third penalty.

2. At Fresno Surgical Hospital in Fresno County, a patient admitted for an arthroscopic procedure on his left knee instead, requiring a second surgery.

"Patient 1 was brought into the OR 6 by RN 1 without rechecking to ensure the correct site (left knee) had been marked... As the team arrived, a time-out (a confirmation to ensure the OR team had the correct patient, side/site of surgery...) should have been announced, but this was not done at the time," state records say.

Later, after the prep on the wrong knee, a time-out was held with all team members present.

"The incorrect site was documented in the OR record as the correct site and no one visually verified the marking of the site to be operated on."

Days later, the patient told state investigators that he was having trouble walking to the bathroom because "he does not have a leg to bear weight on," and was having trouble using crutches as well.

The penalty is $75,000. This is Fresno Surgical's second penalty.

3. At Memorial Medical Center, Modesto, in Stanislaus County, a physician delayed for 17 minutes resuscitation of a patient admitted for an elective outpatient procedure to break down his bladder stones. During the 17 minute delay, the patient incurred irrevocable brain injury, and died 11 days later.

According to state documents, after the procedure, the patient was placed on a gurney to leave the operating room but began "thrashing."  A physician, MD 2,  administered the drug propofol, and the patient immediately calmed down, but in about 60 seconds, stopped breathing.

The physician inserted oral and nasal airways, but a pulse oximeter showed no oxygenation. The physician then administered oxygen by mask. But when a cardiopulmonary resuscitation monitor was brought in, it did not indicate the patient was breathing, and that he did not have a heart rate.

"At some point MD 2 stated another anesthesiologist came into the OR and suggested re-intubation. MD 2 stated he then re-intubated and mechanically ventilated Patient 1."  However no Code Blue was called. No one was assigned to document in the events when the patient was not breathing.

A registered nurse told state investigators: "MD 2's job was to be the captain of the ship and maintain the patient's airway and monitor the patient' vital signs and assess the patient...MD2 did not do his job. We reacted when we saw time was being lost and something needed to be done."

When asked the reason for the delay in resuscitation and calling a code blue, MD 2 told investigators, "I zoned out."

The penalty is $50,000. This is the Memorial's first penalty.

4. Also at Memorial Medical Center, Modesto, the wrong patient received an inferior vena cava filter to prevent a leg blood clot from traveling to his heart and lungs—a clot the patient didn't have.

According to state documents, the error occurred because an ultrasound for a second patient who did have a leg clot, and who was treated in the hospital the same day, was "intermixed" with the record for the first patient.

The mix-up was discovered only because some time later, the first patient returned to the ED, and a new ultrasound was performed showing no clot.

"The Director of Imaging Services (DIS) stated" that prior to the incident, "physicians did not routinely check to make sure the digital ultrasound read on one computer monitor matched the patient for which the electronic health record was being dictated on the other computer monitor," and that "the hospital had no policy and procedure on the processing and dictation of ultrasounds."

The penalty is $75,000. This is Memorial's second penalty.

5. At Placentia Linda Hospital, Placentia, in Orange County, nursing and medical staff failed to report and the hospital failed to investigate an allegation of a witnessed sexual assault by medical doctor 2 (MD).

This "resulted in a subsequent sexual assault of Patient B by MD 2 and an ongoing threat of sexual assault to surgical patients by MD 2 over a period of approximately one year."

The problem became public when "a hospital transporter believed she witnessed an anesthesiologist fondle the breast(s) of a female patient under anesthesia for an outpatient surgical procedure" and reported it to hospital administration the following Monday.

State documents say that during an interview with the chief anesthesiologist, "it was revealed the allegation about MD 2 was not the first one reported to him. 

Approximately a year ago, RN 1 had reported to him that ST 1, the surgical technician who assisted on the procedure, witnessed MD2 touch a female patient's genitals while performing a femoral nerve block…The Chief Anesthesiologist, wanting more concrete evidence, opted to monitor MD2's performance for any further sexual allegations," and did not report to the medical staff or administrators. "MD 2 was not confronted about the incident.

The penalty is $50,000. This is Placentia's first penalty.

6. At Santa Clara Valley Medical Center, San Jose, in Santa Clara County, staff failed to check a patient after noticing that his telemetry signals were not registering on the monitor, resulting in the patient suffering cardiac arrest and death. 

After the monitor technician (MT) made a first announcement that the signals weren't registering, the second announcement wasn't made for another nine minutes.

"When the nurse did assess Patient 1, she found him lying on the floor, unresponsive, and disconnected from the cardiac monitor." Though the emergency team administered cardiopulmonary resuscitation and placed the patient on life support, he sustained brain injury. Life support was removed resulting in his death.

"When asked why there was a nine-minute delay from the first announcement to the second announcement, MT 1 stated she was occupied performing other tasks and lost track of time."

The 83-year-old patient had been brought to the hospital for treatment of a subarachnoid hemorrhage sustained after falling at home.

The penalty is $100,000. This is Santa Clara's third penalty.

7. At St. Mary's Medical Center, San Francisco, in San Francisco County, doctors failed to remove a 60-centimeter stiffener stylet, or guide wire, from a catheter that a surgeon inside a large vein of a chemotherapy patient, requiring another surgery.

Asked if he remembered pulling the guide wire out of the catheter after its placement, the surgeon told state investigators: "This does not follow my routine. I can't remember if I pulled the wire out or just cut across it."

A circulating nurse who was present during the procedure told state investigators "I get that wire when the surgeon pulls it out of the catheter and I put it in a bag.  We don't count it like we do needles, sponges and knife blades.

The penalty is $75,000. This is St. Mary's second penalty.

8. Also at St. Mary's Medical Center, a patient died after an anesthesiologist administered the drug Versed pre-operatively without monitoring respiratory status afterwards. "The patient developed respiratory failure secondary to acute pulmonary arrest."

The patient had been admitted to remove metal screws and plates placed to repair broken bones, according to state documents.

State surveyors investigating the incident asked the anesthesiologist if the patient's respiration, heart and blood pressure was monitored after Versed administration. He replied "No, we only put monitors on when we are doing conscious sedation like in the cath (heart) lab or if a patient was getting a GI procedure. The Versed I gave was to treat the patient's anxiety."

Also, he said he had not told the nurses that he had given the patient Versed.

Asked if there was a policy for giving Versed in the pre-op holding area, the director of perioperative services replied, "There is no policy for that; we are making changes."

The penalty is $100,000. This is St. Mary's third penalty.

9.  At the University of California San Francisco Medical Center, in San Francisco County, the surgical team did not remove a green plastic clip, one-inch by one-quarter inch used to compress layers of the scalp, from the brain of a craniotomy patient.

State surveyors said that the facility had failed to develop and implement a surgical count policy that specified small items would be accounted for prior to closure after brain surgery.

The clip was discovered after the patient returned to the facility with an infection in the area of the brain incision.

"In an interview...the circulating nurse (RN) stated the Operating Room staff never counted Raney clips before or after neurosurgery cases," the state document said. The Operating Room Manager said Raney clips weren't counted because "they were so far away from the surgical area she did not think they could ever fall into the surgical site."

The penalty is $100,000. This is UCSF's seventh penalty.

10. Also at the University of California San Francisco Medical Center, two operating room nurses failed to count sponges, resulting in retention of a laparotomy sponge in a patient's abdominal cavity and a second surgery to remove it.

According to the state documents, the nurses:

  • Ignored the request" from an operating room technician "to reconcile a sponge count discrepancy, a fact he announced 'more than once,' "
  • "Neglected" to call for assistance from the charge nurse during a disputed sponge count
  • Failed to scan lap sponges from the ring stand and place them in counter bags, but instead "visually" counted them directly from the ring stand, and delayed scanning them while counting instruments.
  • Failed to maintain sterility of the surgical field and the room before confirming that the wound was clear of sponges. "They knew a lap sponge was missing, and assumed it 'had to be in the trash.' "
  • Failed to notify the surgeon that a sponge could not be found.
  • Failed to call for a STAT x-ray to rule out foreign body retention.

The penalty is $100,000. This is UCSF's eighth penalty.


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