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Adverse Events Draw $775K in Fines at 9 CA Hospitals

Cheryl Clark, for HealthLeaders Media, October 28, 2013

The incidents, with links to related documents are as follows:

1. At Alvarado Hospital Medical Center, San Diego, San Diego County, a patient admitted from a nursing home because she had fallen, died from bleeding in the brain caused by a subsequent fall while in the hospital. A nurse had turned off the patient's fall alarm to allow her to sit on the edge of her bed, as she had asked.

A second nurse, one of the first responders, said "he heard a loud 'crashing' sound" and found the patient on the floor with a pool of blood beneath her head.

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

2. At Antelope Valley Hospital, Lancaster, Los Angeles County, a patient discharged from the hospital after a colectomy returned three times for emergency department care because of pain before a forgotten surgical object was discovered in his abdomen.

He was sent home with pain medication the first time and given a groin ultrasound and pain medication before being sent home the second time. On his third visit to an emergency department, which was not named in the report, he was given a CT that revealed a retained surgical device.

A subsequent laparotomy removed a Glassman viscera retainer or "Fish" device measuring 9 inches by 6 inches, with a 9-inch attached string connected to a ring two inches in diameter. According to the website of the manufacturer, AdeptMed International, the ring "is an effective indicator of a retained instrument."

According to the state's report, the routine surgical count did not include the device because it was a "miscellaneous" item and not part of the surgical tray. The report does not detail how long the patient was in pain, only that he had "been suffering of abdominal pain for a while now" before the device was discovered.

State investigators said they documented the retained surgical object with an unannounced visit in response to an "entity reported" incident.

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

3. At Community Regional Medical Center, Fresno, Fresno County, a patient admitted for ascending aortic aneurysm repair suffered massive blood loss, cardiac arrest, and loss of oxygen to the brain after the heart surgeon left the operating room prior to the closure of the patient's chest during open heart surgery.

The surgeon instead directed a physician's assistant "to be left in charge, an individual not qualified to be left in charge of the cardiovascular surgery."

State investigators said the patient's loss of blood "required reopening the chest and manual massage of the heart." The patient was subsequently placed on life support.

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