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$9.25M in Fines for Medical Errors Goes Largely Unspent in CA

Cheryl Clark, for HealthLeaders Media, September 6, 2012

In the news briefing last Thursday, Debby Rogers, Billingsley's successor, told reporters that retained surgical objects now account for 27% of reported adverse events in California hospitals. Nothing else, except for hospital- acquired stage 3 or 4 decubitus ulcers, which account for 64% of all adverse events, comes close.

"Many of these patients have to return to surgery and face other complications like infections" that result from the body's reaction to metal, cloth or other material," Rogers said.

According to the latest California report, of the total 5,468 adverse events between mid-2007 and mid-2011, 1,154—more than one in five, were mishaps related to surgery and of those, 850 were due to a retained foreign object.

To make matters worse, the numbers don't seem to be going down.

In FY 07-08, 154 surgical items were found in patients. In FY 08-09, 191; in FY 09-10 there were 265 and in FY 10-11, it was almost as high, 240.

Kizer, former director of the National Quality Forum, says the 2.5-year project's scope of work will include an evaluation of whether more objects are being left inside patients, or whether hospitals are just doing a better job of reporting them.

There are other components to the job as well, such as an examination of possible variation in the way regional state licensing and certification offices assess hospital adverse events, creation of a hospital quality improvement collaborative, and establishment of a patient safety advisory committee.

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