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Immediate Jeopardy: 14 CA Hospitals Fined $850,000

Cheryl Clark, for HealthLeaders Media, December 12, 2011

St. Jude was ordered to pay $75,000. This is its third administrative penalty.

11. At Sutter Solano Medical Center, Vallejo, in Solano County, surgeons failed to remove a lap sponge in a patient who underwent a Cesarean section, resulting in the patient having to undergo a second surgery.

A review of her case revealed that she came to the ED five days after discharge from her C-section complaining of worsening right lower quadrant pain. "A Computed Tomography (CT) scan was done and was suspicious for retained foreign body with a differential diagnosis of possible ruptured appendix that had walled itself off."

Sutter Solano was fined $50,000 for its first penalty.

12. At Torrance Memorial Medical Center, Torrance, in Los Angeles County, surgeons failed to remove a lap sponge. "The facility's failure to implement its policy and procedure to prevent retention of a lap sponge during a surgical procedure for Patient A is a deficiency that has caused, or likely to cause, serious injury or death to the patient and therefore constitutes an immediate jeopardy," according to the state report.

Torrance was fined $75,000. This was its second penalty.

13. At the University of California San Francisco Medical Center, in San Francisco County, a surgeon failed to mark and inject local anesthesia into the patient's surgical site, the right eye area, and failed to observe a timeout prior to surgery. According to the state report, the circulating nurse said "it was 'very chaotic' before the start of Patient 1's surgery," and that she was interrupted four times. "When asked if she reminded Surgeon 1 that a timeout had to be scheduled prior to beginning Patient 1's surgery, she responded, 'I did not, none of us did.'"

"She acknowledged that she failed to act as an advocate for Patient 1 when she allowed herself to be distracted."

UCSF was fined $75,000 for its sixth administrative penalty since 2007.

14. At Ventura County Medical Center in Ventura County, a surgical team failed to properly count surgical implements, resulting in the patient being discharged with a surgical towel that should have been removed. After discharge, "patient A presented at the emergency department with complaints of increased abdominal pain, nausea, vomiting, and abdominal bloating. Radiological studies...showed a distended bowel and a 'swirl-like material" and a "band-like foreign body."

Additionally, according to the state report, several members of the surgical team did not have appropriate training and credentialing for the surgical suite.

The hospital was fined $50,000 for its second 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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