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Immediate Jeopardy: 14 CA Hospitals Fined $850,000

Cheryl Clark, for HealthLeaders Media, December 12, 2011

She was discharged, but then "began to feel terrible again," according to the state report. Eventually, a specialist conducted numerous tests, and told her she needed a second surgery to remove a retained sponge.

"Patient 1 stated she now has a weak bladder and is incontinent," according to the state report. She told state investigators "I feel like I have been robbed of my life having to live with this."

The hospital was fined $50,000 for its first penalty.

2. At Henry Mayo Newhall Memorial Hospital, Valencia, in Los Angeles County, staff administered three times the prescribed dose of an antibiotic, colistin methanesulfonate, resulting in the patient developing acute renal failure requiring dialysis treatments.

"The Progress notes...disclosed the patient complained of numbness in his face, dry mouth, and saying, 'The antibiotics are killing me,'" according to state documents. A nephrologist's initial impression was that the acute renal failure was caused by hypersensitivity to radiocontrast material during a special X-ray procedure.

According to the state's report, the staff or pharmacy failed to administer the antibiotic in divided doses, and gave a full day's dose in each of three eight-hour segments for several days.

The hospital received a $50,000 penalty for its first incident.

3. At Kaiser Foundation Hospital, South San Francisco, in San Mateo County, staff failed to maintain refrigerators at proper temperatures, and as a result, many medications and vaccine doses stored there were frozen, which is said to reduce their effectiveness.

According to the state's report, some 5,000 patients received either "compromised" pneumococcal vaccines, TB tests, or hepatitis B vaccines. The refrigerator's maintenance checks were scheduled every three years instead of every three months.

Kaiser received a fine of $50,000 for its first penalty.

4. At Los Angeles County+University of Southern California Medical Center, surgeons failed to remove a lap sponge from a patient during an appendectomy. The patient came back to the emergency department complaining of abdominal pain and was diagnosed as having a small bowel obstruction.

When a routine postoperative abdominal radiograph was reviewed, it revealed a drain in the right lower quadrant which was diagnosed as a retained foreign body.

LAC+USC was fined $25,000 for this incident, which is its fifth, but occurred prior to 2009.

5. At Lucile Packard Children's Hospital, Palo Alto, in Santa Clara County, a pharmacy technician failed to dilute ammonium chloride per manufacturer's recommendations, and the supervising pharmacist failed to verify accurate preparation, according to state documents. As a result, a newborn who had just had surgery for a congenital heart defect developed seizures.

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