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7 Hospitals Fined for Immediate Jeopardy Mistakes

Cheryl Clark, for HealthLeaders Media, April 14, 2010

Scripps officials said that since the incident, they have reviewed all surgical cases regarding surgical counts and reviewed competency training for nurses and scrub techs.

3. California Pacific Medical Center, Pacific Campus in San Francisco, was fined $25,000 because a surgeon performed arthroscopy on a patient's right knee instead of the left, as intended. "They should have done a time out [a period prior to surgery for checking the right patient, right body part] but they didn't do one, they went straight into the procedure," said the state.

"When the surgeon realized the mistake, he proceeded to do an arthroscopy of both knees even though the consent form was for the left knee only."

4. Sutter Davis Hospital was fined $25,000 for a 2008 incident in which a patient with serious airway diseases and who had neck pain and swelling was administered an iodine contrast material prior to conducting a CT scan.

According to state documents, the patient had a history of iodine allergy, but her medical records were not checked beforehand, nor was a physician in the room as she was undergoing the scan, said the state.

During the CT procedure, "the nurse observed [the patient] having some type of distress, the nurse and technician attempted to reposition the arms, but [the patient's] oxygen level and blood pressure fell and a Code Blue emergency was called," according to state documents.

"Within minutes of receiving the contrast injection, [the patient] experienced breathing difficulty, low heart rate and low blood pressure requiring rescue interventions and interrupted the imaging studies. [The patient] did not respond to stabilizing treatments over the next two hours and expired in the radiology suite."

5. Kaiser Foundation Hospital in Fontana also received two penalties, the first for $25,000 for an incident in 2008 in which a patient undergoing surgery to remove orthopedic hardware from his left knee received first, second, and degree burns from a "triangle" device used to position the knee, according to officials.

After the patient went home after surgery "he felt pain behind his left knee, removed his bandages himself at home and saw blisters," said the state.

The triangle device had been sterilized, but was still too hot when it was placed, according to state documents.

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