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7 Hospitals Fined for Immediate Jeopardy Mistakes

Cheryl Clark, for HealthLeaders Media, April 14, 2010

"There was no procedure listed on how to protect a patient from burns or on how to determine if the flash sterilized instruments were cool enough to be used on a patient," the state documents said.

The Fontana hospital was also fined $50,000 after surgeons in 2009 reportedly left a sponge inside a patient despite the fact that the surgical count of sponges and other surgical devices was correct. It was found only because a physician "had an uneasy feeling there was a retained sponge." The item was detected by X-ray and required a second surgery for removal.

6. St. Joseph's Hospital in Orange was fined $50,000 because a double pneumonia patient who required oxygen was transported for an ultrasound test without a tank containing sufficient amount of oxygen for the amount of time required. "While in the [ultrasound] department, the patient had a respiratory arrest and died," state documents said. "It was observed at the time of the arrest the oxygen tank connected to the patient was empty."

"The patient was transported to the radiology department without a completed and signed checklist showing the patient was stable for transfer," said the state.

Additionally, the state report said, "The hospital chart showed that for the size of the portable oxygen tank used to transport the patient, that on a full oxygen tank at the rate the patient was receiving oxygen, 15 liters per minute, the tank could supply oxygen to the patient for about 45 minutes."

However, the state document shows, the patient was waiting in the radiology room for 60 minutes. The ultrasound technician assistant transported the patient back to their room ... the portable oxygen tank was empty, the patient was observed not to be breathing.

7. St. Bernadine Medical Center in San Bernardino was fined $50,000 for a 2009 incident in which doctors failed to remove a blade extender tip of a Bullard laryngoscope that was used for an exam of the larynx.

"The retention of the blade extender tip in [the patient's] airway had the potential to result in imminent danger due to occlusion of the airway, as a result of aspiration of the blade extender tip," according to the state's report.

The patient had undergone an outpatient lap cholecystectomy. "During a routine follow-up phone call to the patient . . . [the patient] informed the hospital staff that she had 'coughed up a piece of white plastic,'" later identified by the anesthesiologist as the extender tip of the laryngoscope he had used to intubate the patient, the documents said.


Cheryl Clark is senior quality editor and California correspondent for HealthLeaders Media. She is a member of the Association of Health Care Journalists.
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