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.