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Medical Errors at 10 CA Hospitals Draw Fines of $625K

Cheryl Clark, for HealthLeaders Media, August 21, 2013

State investigators faulted the hospital violating its own regulations that require reassessment and continued ongoing assessments for respiratory care, including the intubation procedure and the patient's response to those treatments.

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

4. At St. Jude Medical Center, Fullerton, in Orange County, a patient was admitted for cancer surgery on the right kidney when the neoplasm affected the left kidney. The error was discovered by a pathologist who notified the physician that the surgically removed kidney "was normal."

State investigators said that when the physician checked with another hospital, where the diagnostic studies were performed, a CAT scan showed a left mass consistent with renal cell carcinoma.

"This report was not a part of the patient's medical record at St. Jude medical Center, where the surgery was performed. At the time of the surgery, MD 1 (the surgeon) had the reports at his office."

According to the state report, the essential step of checking with the patient failed to prevent a wrong-side surgery. "MD 2 stated he asked the patient and the patient said the right side."

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

5. At Sharp Memorial Hospital, San Diego, San Diego County, surgeons
came close to removing a patient's healthy right testicle instead of the unhealthy left one, resulting in an unnecessary incision to the patient's right groin. The error was stopped when a pre-op nurse said, "Wait, it's left side."

According to the report, the surgeon stated the incision was superficial about a couple inches in length, so he closed it with a surgical adhesive bond.

"The surgeon acknowledged that, 'it was our job to concentrate at that moment and we didn't. Everybody heard, but didn't listen.' "

The report said that the hospital's surgical team failed to follow its own policies, which say that patients "may not be transferred to an operating room or given anesthesia until the planned site/side has been verified and initialed by the surgeon," that "the anesthesiologist, scrub person and circulating RN will verbally and visually confirm patient identity, correct procedure, correct surgical site and review consent."

The team also failed to perform an appropriate 'Time Out,' during which "the entire team must pause and focus their attention to verify the correct patient, the correct procedure and the correct side/site is initialed," according to the state report.

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

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