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12 Hospitals Fined For Patient Harm, Deaths in CA

Cheryl Clark, for HealthLeaders Media, June 6, 2011

"The hospital failed to implement several procedures that help safeguard patients from wrong site surgery," the state said, including the failure to review the patient's consent form, verify the correct site and document that on the pre-operative checklist."

Anaheim Regional received a $50,000 fine.

9. At Peninsula Medical Center in Burlingame, San Mateo County, surgeons failed to remove a piece of sponge used during an eye procedure. In an outpatient clinic, a physician noticed a small fragment of sponge extruding from the conjunctiva of the patient's right eye. The patient had to undergo a second surgery that day to remove the fragment.

According to state documents, the hospital's operating room nursing director said, "They don't count sponges during eye surgery, the surgeon does an internal count in his head."

Peninsula received a $50,000 fine.

10. At Emanuel Medical Center in Turlock, Stanislaus County, hospital teams failed to follow its policies regarding safe use of droperidol, a drug used for nausea and vomiting, which has significant risk of potentially fatal adverse events if it is not used according to strict protocols. It also has been given a black box label by the U.S. Food and Drug Administration.

Patients who receive it must first undergo an electrocardiogram to avoid heart rhythm disturbances in some patients. And patients with certain heart function abnormalities should not receive it at all.

A review of the records for 12 of 61 patients who received the drug at this hospital during a three month period last year determined that five of them either had not had the required ECG testing or had test results that should have precluded them from receiving the drug.

The physician who prescribed the drug for those patients "said he wasn't aware of the hospital's requirements for prescribing the drug (and) wasn't aware of the boxed warning by the FDA..."

The state documents did not indicate whether any of the patients had suffered any adverse events as a result of their receiving the drug.

Emanuel received a $50,000 fine.

11. At Kaiser Foundation Hospital in San Francisco, a patient who underwent a Caesarean section had to undergo a second procedure to remove a 4-centimeter proximal segment of a fetal scalp electrode, state documents said. The patient developed abscesses.

State documents said that the electrode had become "entangled during the surgery" and that it was not a practice in the operating room to account for electrodes, although that policy will be changed.

Kaiser received a $50,000 fine.

12. At Dominican Hospital in Santa Cruz County, an oncologist transposed two numbers resulting in a testicular cancer patient receiving "100 mg. per meter squared per day of cisplatin instead of 20 mg. per meter squared, for the four days he was administered the chemotherapy." Additionally, the pharmacist, despite multiple checks, failed to implement policies and procedures to verify appropriate dose.

As a result, the patient developed ringing in the ears, a feeling of being bloated, difficulty urinating and other worsening symptoms requiring insertion of a catheter and had to be admitted to the intensive care unit with acute renal failure due to cisplatin overdose and a course of dialysis, according to state documents.

Dominican received a $50,000 fine.


Past immediate jeopardy fines:
November 2010
April 2010
January 2010
September 2009

See Also:

Commentary: CMS Needs to Come Clean on Immediate Jeopardy


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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