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Immediate Jeopardy Fines for 12 California Hospitals

Cheryl Clark, for HealthLeaders Media, December 21, 2012

To date, 141 of the state's 450 acute care hospitals have received 254 fines totaling nearly $10.4 million, $7.6 million of which has been collected.

According to state documents, which can be found on the state website by county, these are some details of each incident:

1. At Kaiser Foundation Hospital, Oakland, Alameda County, a healthy 29-year-old woman was having a congenital birthmark removed from her upper lip. The physician used a Sharplan laser with helium.

But as soon as the laser wand was activated near the birthmark, "the patient's face and neck began to swell up 'secondary to the helium gas of the laser device,'" trapping air. The patient's blood pressure began to fall and a code blue resuscitation was unsuccessful.

State investigators said that the ear-nose-throat (ENT) specialist failed to read or follow extensive warnings in the device's 30-page manual that specifically instructed proper laser positioning to avoid a gas embolism. Hospital policy regarding privileges for the ENT department "is not per device but rather per condition or anatomic location" and "lasers are not part of the checking process that the operating room manager does."

The physician involved told investigators he didn't realize the device's high pressure, and said "I did not read the manual (with instructions for use.)"

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

2. At Kaiser Foundation Hospital, San Diego County, an 85-year-old man admitted for surgery to remove his left kidney, which had a mass, instead woke up without his right one.

The surgical suite did not have the patient's radiology images, which could have prompted the surgery team to catch the mistake, because the surgeon did not think they "were relevant to this case because the procedure did not require a review of the anatomy or vasculature."

The case was complicated by the fact that the patient himself "pointed to" the right, incorrect, kidney, misidentifying the one that was diseased, and the surgical team didn't independently check.

The error was discovered only after the pathologist told the surgeon that there was no mass in the removed kidney submitted for testing. The patient became tearful in describing the incident to state investigators, saying he now suffers "chronic fatigue," is unable to "perform his previously enjoyed hobbies of dancing and golfing," and is solely dependent on his wife and other family members.

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

3. At Kaiser Foundation Hospital, San Rafael, Marin County, surgeons neglected to remove a 3- or 4-inch piece of iodoform- impregnated gauze. The epigastric procedure required three separate sterile instrument and supply table set ups, and multiple technicians and a surgeon, none of whom remembered the gauze being used during the procedure.

The retained gauze was discovered five weeks after the patient's surgery when she felt pain in her abdomen and went to see a doctor.

"Physician B. thought an incision on her abdomen was infected by a stitch underneath the skin," says the state report. The patient stated "that the physician opened up the incision and pulled a long strip of gauze out of her abdominal area."

A member of the surgical staff told investigators that the hospital's surgical object count policy required a count of sponges, needles and sharps, but was not specific about other items such as gauze.

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

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