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

Cheryl Clark, for HealthLeaders Media, October 28, 2013

Asked for an explanation, the surgeon said he had allowed the physician's assistant "to practice above her privilege card as 'she was preparing for an advanced quality practice exam and for that, she needed so many cases with opening and closing the chest and to cannulate the heart." The surgeon said he had always been there when she did this procedure "until this time."

State investigators wrote that the incident was reported through "an anonymous complaint," suggesting that the hospital may not have properly reported the incident as required by law.

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

4. Also at Community Regional Medical Center, Fresno, Fresno County, a patient had to undergo surgery and suffered paralysis of both legs after a physician told a physician's assistant to remove an epidural catheter, a procedure "neither was privileged (to perform)."

The patient had agreed to a procedure in which pain medication is injected into the epidural space in the lower back.

The patient was on Lovenox, a blood thinner, which complicated the case because according to the medication packaging, "epidural catheters were not to be removed when patients were being treated with blood thinners because of the risk of uncontrolled localized bleeding."

That removal led to the patient developing an epidural hematoma, which required surgery. The surgery resulted in the patient's lower limb paralysis.

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

5. LAC/Harbor-UCLA Medical Center, Torrance, Los Angeles County, a patient lost a great deal of blood, suffered altered mental status and died after the hospital team failed to perform current lab studies prior to the patient's scheduled knee replacement surgery.

According to the state's report, the patient's lab work and other testing was done five months prior to the surgery. In the interval, other operations and infections "had resulted in considerable distortion of the anatomy," which extended the duration of surgery to more than five hours. During that time the patient lost a critical amount of blood.

The hospital was also faulted because the surgical team failed to pre-order units of blood, and the hospital's blood bank was unable to emergently deliver sufficient amounts of blood to keep the patient alive. State investigators were told that the surgery was not supposed to require blood transfusion because a tourniquet was being used.

Records indicated that the surgeon had "completely transected" the patient's popliteal artery, which supplies blood to the knee joint and muscles in the upper and lower leg, in at least two places, but because of the tourniquet, "no bleeding was evident."

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

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