13 Hospitals Fined for Mishaps, Never Events

The specifics problems were:

1. At Whittier Hospital  Medical Center in Los Angeles, the wrong patient was taken for surgery a dilation and curettage procedure, resulting in the operation being initiated in a 63-year-old patient with colon cancer, who was scheduled for a Port-a-Cath device for chemotherapy. The operation "was terminated when found that the patient did not have a uterus." The arm-band was not checked, the "time-out" was described as "quick," and there was no documentation that correct side/site checks were performed. Also the patient had been put to sleep prior to the "time out," contrary to anesthesia protocols.


2. At Brotman Medical Center in Culver City, a patient received hydromorphone by intravenous push rather than subcutaneously as prescribed, resulting in the patient going in to a coma and requiring mechanical ventilation. The patient had been admitted to the hospital for a colon resection. An investigation determined that hydromorphone syringes were improperly labeled and their administration in at least two patients was not independently verified by a second nurse, as hospital policy requires.


3. At Clovis Community Medical Center near Fresno, lack of communication between two physicians and the failure to check an INR (international normalized ratio) test for a patient resulted in potentially adverse effects from the anti-clotting drug warfarin, which conflicted with amiodarone, another drug the patient was taking.


4. At Hollywood Presbyterian Medical Center in Los Angeles, a patient received the wrong blood type because a staff member went to the wrong patient's room. The error caused a dangerous hemolytic reaction that resulted in the patient's death.


5. At John Muir Medical Center in Concord, the failure to properly restrain a patient for a radiology exam resulted in a fall that caused a ruptured right eyeball. The result was that the patient became blind in that eye.


6. At Los Angeles County Harbor UCLA Medical Center, a surgical sponge was left in a patient for more than 10 months, despite the patient complaining of pain, nausea, and vomiting. Another surgery was required to remove the sponge and a cyst that had formed around it.


7. At Saint Agnes Medical Center in Fresno, the facility's third such penalty, was assessed after a patient died following surgery because staff did not intervene quickly enough to remedy her abdominal hemorrhaging after a hysterectomy.  


8. At St. Francis Medical Center in Lynwood, potassium levels weren't monitored in two patients resulting in cardiac emergency. One of the two patients died.


9. At St. Jude Medical Center in Fullerton, a plastic drape or towel used to guard a sterile field was repositioned by the surgeon to retract the patient's bowel and subsequently became hidden in the patient's body cavity. The drape was not counted like other devices, such as sponges or surgical tools. "After the patient went to the recovery room Surgeon D called Nurse B to ask 'did we remove the drape?' Nurse B stated she told the surgeon she did not remember the drape being removed," the statement of deficiency says. Removing the drape required a second surgery requiring intubation, that carried additional risk of respiratory problems, increased blood pressure or heart rate, damaged teeth, lips and swelling, or injury to the throat or larynx.


10. At Scripps Mercy Hospital in San Diego, faulty respiratory equipment was used to provide ventilation support to a trauma patient with a brain injury on Sept. 1.  Also, the hospital failed to make sure that the patient's respiratory status was checked by a licensed nurse and respiratory therapist during transport of the patient to a portable MRI unit located outside the facility. When the patient was administered vecuronium and sedated for the MRI, the patient went into respiratory and cardiac arrest. An investigation determined that the transport ventilator lacked the "on/off" knob and the "pressure relief knob and had not been maintained since April."


11. At the University of California Irvine Medical Center, hospital officials failed to promptly investigate an incident involving a patient's complaint that she was sexually abused by a staff member. "The facility failed to ensure the safety of other patients by allowing the alleged abuser continued contact with other patients after the reported allegation," the state's record says.


12. At the University of California Irvine Medical Center, staff failed to watch a patient at risk for falling, who subsequently got out of bed and fell, sustaining a fatal laceration to the back of the head. The laceration was so severe that the patient's blood pressure subsequently dropped, he lost consciousness, which he did not regain. Staff also failed to take precautions, such as making sure that a walker was left in the room for the patient's use or that non-skid socks were on his feet.


13. At the University of California San Diego Medical Center, surgeons operating on a patient for lumbar stenosis left a Raytec (x-ray detectible) surgical sponge in her spine area, which wasn't discovered for three months. The facility failed to follow its own procedures, which required that post-surgical x-rays be taken to make sure all foreign objects had been removed.  A second surgery was required to remove the sponge.


14. At the University of California San Francisco, failure to establish safety standards for administering Flolan, a drug that opens up blood vessels in the lung in patients with pulmonary hypertension. The mishap resulted in a patient receiving 23 times the prescribed dose, which proved fatal.  The infusion device did not meet manufacturer's recommendations and one registered nurse with no validated competency in using the device was assigned to provide the patient's care.