Hospitals Fined for Forgotten Surgical Devices, Wrong Surgeries, Burnt Patient

5. At Alta Bates Summit Medical Center, Summit in Oakland, in Alameda County, a quarter-sized ring/band sizer used during heart valve repair was allegedly left in a patient's pericardial sac and "a major chest surgery was required to remove it. After the chest surgery, (the patient) experienced complications [that included] kidney failure." The patient's post-operative course was complicated by pooled blood that also required surgery, but it wasn't until 11 days later that a CT scan detected the sizer.

6. At Loma Linda University Medical Center in Loma Linda, in San Bernardino County, surgeons reportedly left a surgical sponge inside a patient undergoing a liver transplant. The patient had to undergo an additional surgery to retrieve the sponge about 12 hours later. The incident investigation revealed problems with the hospital's system for accounting for counts for items used during surgery, an accounting that is not placed in the patient's medical record. This is the second penalty; the first was for a potentially fatal medication overdose, according to the state.

7. At Los Angeles County University of Southern California, Los Angeles, surgeons allegedly neglected to remove two laparotomy towels and three laparotomy sponges from a gunshot patient who underwent surgery to remove the bullet.

Hospital officials reported that counts of all materials used during the procedure were correct. X-rays to detect foreign surgical objects were negative. Even the use of a fluoroscopy failed to detect the items. The items were finally detected after the patient developed a fever and rapid heart beat, and another bullet was suspected as causing the infection. After a CT scan located the towels and sponges, the patient underwent surgery for removal. This is the third penalty against LAC/USC, said the state.

8. At Redwood Memorial Hospital in Fortuna, in Humboldt County, a guideware used during cardiac catheterization, which was reportedly left inside the patient, migrated up to the patient's neck. It required an emergent transfer of the patient to another acute care hospital's catheterization lab for a second procedure to immediately remove the guide wire. "These failures placed (the patient) at potential risk for complications, internal injuries and/or death from the migrated guide wire." The involved physician allegedly told state investigators, "I spaced out and it was a regrettable incident," said the state.

9. At Mendocino Coast District Hospital, Fort Bragg, in Mendocino County, a staff nurse who was allegedly no longer qualified to conduct fetal heart rate for a woman in labor incorrectly wrote that the fetus had a 140 to 150 beat per minute heart rate.

The patient, who was giving birth, had adequately dilated and was taken to delivery but the baby was stillborn. "Review of documents . . . led to the conclusion that the staff nurse had applied the monitor incorrectly and the monitor was recording the mother's heart beat rather than the baby's. The staff nurse who was appropriately qualified was reportedly busy with another patient," said the state.

10. At Tri-City Medical Center, Oceanside, in San Diego County, a 91-year-old patient with dementia died after sustaining a femoral fracture when she fell out of bed. Documents reveal that fall precautions were ordered, but a pressure alarm was not turned on and although the patient was wearing a Posey vest, it was not attached to the bed, said the state.

11. At Kindred Hospital in Ontario, in San Bernardino County, staff failed to observe physician's orders to have a one-to-one sitter to prevent an agitated brain injury patient from pulling out a tracheostomy tube, IV lines, and feeding tubes. "There was no documentation that there was a one-to-one sitter in the room." That "resulted in (the) patient pulling out his tracheostomy tube . . . and suffering cardiac and respiratory arrest, and subsequently expiring," noted the state.