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Immediate Jeopardy: Words No Hospital Official Wants to Hear

Cheryl Clark, for HealthLeaders Media, June 3, 2009

In my many years of writing about hospitals and their problems, I know this:

Medical and administrative executives dread nothing more than to hear that their hospital's failure to comply with license requirements came close to causing—or actually did cause— injury or death to a patient. Jeopardy is not the name of a game. It's their biggest nightmare.

The 14 financial penalties levied against 13 California hospitals last month re-opened the wounds those tragic incidents inflicted on the hospitals' reputations and the careers of the individuals involved, not to mention the patients and their families, even though the events happened as much as six to eight months earlier.

Perhaps adding salt to those wounds, California officials have held six press conferences in the last two years to announce the 87 financial penalties so far assessed each of the hospitals where such events occurred. And each time, they have thrown a public spotlight on documents that describe, frequently in explicit detail, the precise sequence of events leading up to the dreaded event.

The wrong-site surgery, the fatal medication error, or the sponge left inside the patient.

The "awake" surgery when the anesthesia delivery equipment went unfixed, the delayed medication order, the subcutaneous medication that was given intravenously, the fatal fall, the patient who suffocated to death in restraints.

Who made the mistake, who forgot protocol, who altered a record, and who said what to whom is all explained right there on a state Web site for the public to easily see.

The $25,000 penalty the state now imposes is hardly comparable to the shame (even though the fines go up this year to $100,000 for repeat offenses). And while rural hospitals have not suffered as much from these reports as have larger hospitals where more complex patient care is routine, the impact can be devastating on the morale of the entire staff and even an entire community.

California officials and consumers argue that the publicity surrounding such events is a strong motivator for health officials to design and implement systemic changes that make it much easier do the task correctly than to make a mistake.

Apparently, there is similar thinking among the members of the Senate Finance Committee. In their report one month ago, one of their many quality improvement proposals was the imposition of federal financial penalties against any hospitals "that have been cited by the Secretary for deficiencies that posed immediate jeopardy to the health or safety of patients."

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