Medical Errors Draw Fines for 7 CA Hospitals
8. Also at St. Mary's Medical Center, a patient died after an anesthesiologist administered the drug Versed pre-operatively without monitoring respiratory status afterwards. "The patient developed respiratory failure secondary to acute pulmonary arrest."
The patient had been admitted to remove metal screws and plates placed to repair broken bones, according to state documents.
State surveyors investigating the incident asked the anesthesiologist if the patient's respiration, heart and blood pressure was monitored after Versed administration. He replied "No, we only put monitors on when we are doing conscious sedation like in the cath (heart) lab or if a patient was getting a GI procedure. The Versed I gave was to treat the patient's anxiety."
Also, he said he had not told the nurses that he had given the patient Versed.
Asked if there was a policy for giving Versed in the pre-op holding area, the director of perioperative services replied, "There is no policy for that; we are making changes."
The penalty is $100,000. This is St. Mary's third penalty.
9. At the University of California San Francisco Medical Center, in San Francisco County, the surgical team did not remove a green plastic clip, one-inch by one-quarter inch used to compress layers of the scalp, from the brain of a craniotomy patient.
State surveyors said that the facility had failed to develop and implement a surgical count policy that specified small items would be accounted for prior to closure after brain surgery.
The clip was discovered after the patient returned to the facility with an infection in the area of the brain incision.
"In an interview...the circulating nurse (RN) stated the Operating Room staff never counted Raney clips before or after neurosurgery cases," the state document said. The Operating Room Manager said Raney clips weren't counted because "they were so far away from the surgical area she did not think they could ever fall into the surgical site."
The penalty is $100,000. This is UCSF's seventh penalty.
10. Also at the University of California San Francisco Medical Center, two operating room nurses failed to count sponges, resulting in retention of a laparotomy sponge in a patient's abdominal cavity and a second surgery to remove it.
According to the state documents, the nurses:
- Ignored the request" from an operating room technician "to reconcile a sponge count discrepancy, a fact he announced 'more than once,' "
- "Neglected" to call for assistance from the charge nurse during a disputed sponge count
- Failed to scan lap sponges from the ring stand and place them in counter bags, but instead "visually" counted them directly from the ring stand, and delayed scanning them while counting instruments.
- Failed to maintain sterility of the surgical field and the room before confirming that the wound was clear of sponges. "They knew a lap sponge was missing, and assumed it 'had to be in the trash.' "
- Failed to notify the surgeon that a sponge could not be found.
- Failed to call for a STAT x-ray to rule out foreign body retention.
The penalty is $100,000. This is UCSF's eighth 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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