California health officials fined 13 hospitals a total of $650,000 Wednesday for 16 "immediate jeopardy" medical mistakes that caused or could have caused patient harm, including at least three that may have led to patient deaths.
"In issuing these administrative penalties, our goal . . . is to improve the quality of healthcare at all California hospitals," said Kathleen Billingsley, deputy director of the California Department of Public Health. "We want California hospitals to be successful in their efforts to reduce hospital acquired infections, decrease medical errors and eliminate surgical errors."
Billingsley said that money from the penalties eventually will be used on projects "to determine how these violations or deficiencies can be decreased and eliminated over time."
This brings the total number of "immediate jeopardy" penalties to 134 filed against 90 facilities since a law allowing monetary fines took effect Jan. 1 2007, with a total of $3.675 million assessed so far. Of that amount, $2.3 million has been collected, Billingsley said. She has issued announcements of earlier fines on eight prior occasions.
Of the 134 fines, 22 of them are currently under appeal or in litigation, she said.
The state assesses hospitals fines of $25,000 if the medical error occurred in 2007 or 2008. In 2009, the amount rose to $50,000 for the first violation, $75,000 for the second, and $100,000 for the third or subsequent violation.
Most of the hospital errors in this round of announced fines occurred in 2009, although several occurred in 2008.
Asked why there is such a delay in announcing the penalties, California Department of Public Health spokesman Ralph Montano explained "every administrative penalty has to go through a review process. Some take longer than others. We do a thorough job. When it is completed it is released."
The incidents announced Wednesday were:
1. At Hoag Memorial Hospital Presbyterian in Newport Beach, a metal wheelchair gurney was brought into a room housing an MRI machine, which was against hospital policy. When the MRI was turned on, the gurney was drawn in by the magnetic force, crushing the left lower extremity of a patient undergoing treatment, state investigators said in their report. This is Hoag's third fine.
2. Unnoticed by the operating room team at Sharp Grossmont Hospital in San Diego, a surgeon marked and removed the wrong side of the skull of a 93-year-old man undergoing surgery during repair of a bleed in his brain. As a result, the other side of his skull bone had to be removed for a second surgery, requiring a longer period of anesthesia. This is the second fine for Grossmont.
"The entire surgical team failed to ensure that the correct surgical side was operated on," state investigators said in their report.
3. John F. Kennedy Memorial Hospital in Indio received four penalties totaling $100,000 for incidents in 2008 involving the use of nurses who weren't trained or certified to perform emergency room tasks. State investigators documented the problems in four reports, one of which implicated the facility for failing to ensure nursing clinical competency in the death of a two-year old boy.
The infant remained in the emergency room instead of being transferred to the neonatal intensive care unit, prompting the director of the ED to tell state officials: "That baby didn't have to die," according to the state report.
"The employee file for RN 1 . . . indicated RN 1 was hired by the facility on July 7, 2008 (three and a half weeks prior to being assigned to this critical baby)," the report said. "The file indicated RN 1 did not have PALS (Pediatric Advanced Life Support) certification or validation of ED clinical competencies."
4. At Santa Clara Valley Medical Center in San Jose, emergency room staff failed to accurately diagnose a patient with a hemoglobin count below half of what is normal. "RN A stated that if he had been aware the patient's hemoglobin was 6.1 he would have assessed him as a level 2 acuity, which would have changed the priority for the patient to immediately be medically screened by the physician when the next room was available. As a level 3, the patient had to wait until the urgent cases had been seen," investigators wrote.
"The patient was in the ED waiting room for approximately seven hours with a medical emergency condition without a medical screening examination by a physician, which could cause or likely cause death."
The patient was later "found in the lobby unconscious and a code blue cardiopulmonary resuscitation was started . . . The resuscitation was unsuccessful and the patient expired."
5. At St. Jude Medical Center in Fullerton, several emergency room systems intended to monitor patients in cardiac distress failed to work to alert staff of changes in a patient's heart rate, such as an audible alarm and a visual alarm. When the patient's cardiac monitor showed "0" indicating no heart rhythm, "the nurse stated she thought the monitor leads must have come off," according to the state.
"She stated she could see the patient sitting upright on the gurney and thought the patient was alright. She did not go over and check the patient ... The Clinical Clerical Technician walked by the patient, noticed something was wrong with the patient, called the physician and a Code Blue (cardiac resuscitation) was started."
"The patient's bedside monitor showed no heart rhythm. Resuscitation was attempted for 21 minutes, was unsuccessful and the patient was pronounced dead," the state concluded.
6. At Los Angeles Community Hospital, staff failed to apply soft restraints to a patient, as a physician ordered, leading to the patient removing his tracheostomy, the investigators wrote.
"Additionally, Patient 1 was subjected to a delay in airway management when Staff B failed to establish an open airway and administer oxygen immediately after finding the patient had pulled out his tracheostomy tube. A Code Blue was called, and during the cardiopulmonary resuscitation, the patient was found with no vital signs. Patient 1 subsequently expired due to cardiorespiratory arrest."
7. At Kaiser Foundation Hospital in Oakland, emergency room staff failed to double-check medication orders with drugs sent from the pharmacy. The error resulted in a 90-year old patient receiving a variety of blood pressure and stomach ulcer medications and potassium chloride intended for a different patient.
A rapid response team was called in when the man went into "severe respiratory distress, breathing 4-6 breaths per minute" and with a fluctuating blood pressure." A physician interviewed by the investigators "said he could not rule out that the blood pressure medications administered in error caused the severe change in Patient A."
The man was intubated and on a ventilator, and his "brain was not responding ... the ventilator … is keeping him alive," the investigators wrote.
8. At Marina del Rey Hospital in Los Angeles officials failed to assure that a registered nurse continuously assessed a patient's oxygenation when the cardiac monitor strip documented decreased oxygen. The failure resulted in a decrease oxygen saturation and a Code Blue, and the patient had to be intubated and connected to a ventilator, said the state.
9. At California Hospital Medical Center in Los Angeles, staff erred in administering Methotrexate, a chemotherapy, to a patient as treatment for ectopic pregnancy. In fact, the patient was not pregnant. And over the next eight days, the patient developed immunosuppression, severe neutropenia, leukopenia, renal function decline, and oral, esophageal and skin ulcerations, according to the state.
The "policy and procedure failure, relating to the use of chemotherapeutic medication on a patient who was not pregnant, resulted in Patient 1 being erroneously administered Methotrexate and subjected the patient to serious complications and harm," the investigators wrote.
10. At Western Medical Center in Santa Ana, surgeons left a laparotomy sponge in a patient during an emergency Cesarean section and "failed to conduct appropriate sponge, needle and/or instrument counts," investigators wrote.
"Patient #1 had to undergo the risks of another major surgery and general anesthesia to remove the retained sponge," investigators wrote.
11. At Sharp Memorial Hospital in San Diego, the surgical team forgot a sponge in the pleural cavity during an aortic valve replacement procedure. The sponge "had to be removed during a second surgical procedure," the investigators wrote.
12. At University of California San Diego Medical Center, state officials said, a patient required additional invasive procedure to remove a retained guide wire from his right atrium. The state report said the procedure was performed by a first-year intern with a third-year internal medicine resident in attendance for supervision. This is UCSD's third fine.
13. At San Francisco General Hospital, surgeons left a 4-inch by 8-inch gauze sponge in a patient. The object went unrecognized for three months when the patient returned to the hospital complaining of a foul-smelling discharge. "The sponge was not detected until it had tunneled through her abdominal wall into her vagina," according to the state.