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CA Fines 14 Hospitals for Medical Errors

Cheryl Clark, for HealthLeaders Media, August 31, 2012

8. At Kaiser Foundation Hospital, South San Francisco, in San Mateo County, a Ray-Tec or "tuck" sponge was left undetected in a patient for more than six months, even though the patient had come back into the hospital for a second surgery to debride the wound that had failed to heal.

"When this surveyor asked the surgeon if he could remember whether or not he announced (the use of) a deep tuck sponge, he replied, 'I don't remember if I did.' "
This is the hospital's second penalty and carries a $75,000 fine.


9. At Menlo Park Surgical Hospital, Menlo Park, in San Mateo County, a  "hysteroscopy (visual instrumental inspection of the uterine cavity) set up was prepared and used on the patient instead of a cytoscopy (inspection of the interior of the bladder by means of a cytoscope) set up, causing Patient-A's bladder to rupture," documents show.

The error resulted in the patient, who had come to the hospital for endometrial surgery, having to use a foley catheter.  The state said the hospital did not follow its own "Time-Out" policies, especially as it should apply to equipment.


10. At Saint Agnes Medical Center, Fresno, in Fresno County, surgeons failed to remove a surgical towel from a patient, which went unrecognized for four months. The lapse resulted in the patient suffering a small bowel obstruction, undergoing additional surgery, preventable pain, injury and harm, the state document said.

The towel went unrecognized even though the patient came back to the hospital ED after the surgery "complaining of nausea, vomiting, and abdominal pain."

"The hospital failed to implement their surgical count procedure for the surgery of Patient 1," the state report said. "This failure directly led to a surgical OR towel being retained in the patient for four months" which "led to an additional hospitalization," and "directly led to surgery for a small bowel obstruction.


11. At Saint Francis Memorial Hospital, San Francisco, in San Francisco County, surgeons forgot to remove a surgical sponge in a patient who underwent spine surgery.  The sponge was not discovered until he returned for a routine post-op exam, and lumbar spine x-rays showed it.

The report says hospital staff performed a root cause analysis but "didn't come up with a definitive answer" and that "everyone did what they were supposed to."

Investigators asked the hospital's director of perioperative services why, if the root cause analysis showed the staff followed policy on sponge counts, a sponge was still left in a patient. The director replied that an extra sponge might have been in the room, or that " 'another person' came into the room during the case and left a sponge there."

The state report also faulted the hospital's policy because it did not include any information regarding competency validation, or "specify if the count process was part of the operating room staff annual competency or if observational audits of staff were done to ensure compliance."

This is Saint Francis' first penalty, which carries a $50,000 penalty.


12. At Simi Valley Hospital & Health Care Services, Simi Valley, in San Francisco County, surgeons neglected to remove a surgical sponge in a patient who underwent a hysterectomy in 2007. The sponge was not discovered until 2011.

Investigators looked back at the records on the case, and discovered that "all sponge, lap, and instrument (blade) counts were correct."

In 2011, the patient came in for an unrelated abdominal surgery, and surgeons discovered a small bowel mass they recommended she have removed at a later date, which she did.

"Following the resection of the mass and a portion of the small bowel that the mass was attached to, the specimen was sent to pathology. According to the pathology report the subserosal (below a serous membrane) nodule (mass) is seen to contain white gauzy material with occasional broad light blue fibers."

"The facility's failure to ensure the sponge count was correct, and that no sponge was retained in Patient A following the surgery...(in) 2007, created a situation that was likely to cause serious injury or death to the patient," the state report said.

This is the hospital's fourth penalty, but because the incident happened prior to 2009, it carries a $25,000 penalty.


13. At St. Jude Medical Center, Fullerton, in Orange County, surgeons failed to remove a sponge that went undiscovered for 2.5 months, "with delayed wound healing and the increased risk of infection," the state report said.

The patient had undergone bilateral mastetctomies and breast reconstruction. While in her doctor's office for a post-surgical visit, she "complained of irritation at a right axilla (armpit) incision site. The physician examined the area and found a sponge protruding, which the physician removed."

According to the state report, during the surgery "a Ray-Tec sponge was missing." An x-ray was ordered to determine if a foreign body was in the patient, but no foreign object was seen.

On further inquiry, investigators discovered that the physician did not review the chest x-ray. "Instead, the results were read ...over the phone. A subsequent review of the chest x-ray showed that the x-ray did not extend to the patient's axillary area."

This is the hospital's fourth administrative penalty and carries a fine of $100,000.


14. At the University of California Irvine Medical Center, Orange, in Orange County, surgeons neglected to remove a laparotomy sponge from a patient with testicular cancer who underwent two surgeries over a 12.5-hour period.

State investigators faulted the hospital's surgeons for failing to have repeat time-outs between procedures and when informed at one point that the sponge counts weren't correct, failed to conduct an x-ray to determine if the objects were still inside the patient.

Subsequently, another x-ray after surgery while the patient was in the ICU revealed a retained lap sponge on the upper right of the abdomen, and the patient had to undergo a repeat surgery.

"The Director of Perioperative Services...was unable to determine the times when the sponge counts were done and why there were no sponge count times indicated on the intraoperative record. She was unable to explain why there was no documentation of a change of shift count either."

The fine is $75,000 for the hospital's fourth penalty.


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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