Another 14 California hospitals have been ordered to pay fines totaling $850,000 in the latest round of medical errors involving immediate jeopardy to patients, state health officials said last week.
These incidents include seven retained foreign objects, including a 2.5 cm temporary pin used in a woman's spine surgery. The pin apparently became dislodged and was not discovered until it began to impinge on her airway, impeding her ability to breathe.
Other forgotten surgical materials included an 8 x 5 mm metal screw cap, which was part of a breakaway portion on implanted hardware; a surgical towel; and four laparotomy sponges, including one that went undiscovered for eight months, causing chronic infections and rehospitalizations.
Other incidents that placed patients in immediate jeopardy of harm or death included a "Code Pink," in which a newborn was abducted from a labor and delivery unit despite the use of a bracelet designed to signal an alarm if an infant is taken from the area; a morphine overdose which resulted in a patient's death; and the administration of "compromised" medications and vaccines, which were incorrectly refrigerated to freezing temperatures, to an estimated 5,000 patients.
Under California state laws, penalties are assessed at $25,000 if the incident occurred prior to 2009, but after 2009 the amount is raised to $50,000 for the first violation, $75,000 for the second, and $100,000 for the third or subsequent penalty.
Two of the hospitals that received these administrative penalties, Scripps Memorial Hospital in La Jolla and Mission Hospital Regional Medical Center in Mission Viejo, received the maximum fine of $100,000 because they had more than two prior penalties since the beginning of 2009. In this round, Scripps received its sixth penalty and Mission its fourth.
Since the state law allowing financial penalties for immediate jeopardy incidents took effect in 2007, nearly one in four California hospitals, or about 125, have been ordered to pay 214 financial penalties totaling nearly $7.7 million. About $5.1 million of that has been collected, according to California Department of Public Health spokesman Ralph Montano. Several hospitals are appealing portions of the remainder.
According to state documents, which can be found on the state website by county, these are some details of each incident:
1. At Fresno Surgical Hospital in Fresno County, surgeons failed to remove a lap sponge in a patient who continued to have infections after her discharge for eight months. "Patient 1 stated her physician continued to place her on antibiotics (Cipro, Levaquin) for about 3-4 months making changes of the type of antibiotics until she collapsed at home and was admitted into a hospital for 11 days to be treated with IV antibiotics for infection," according to the state's report.
She was discharged, but then "began to feel terrible again," according to the state report. Eventually, a specialist conducted numerous tests, and told her she needed a second surgery to remove a retained sponge.
"Patient 1 stated she now has a weak bladder and is incontinent," according to the state report. She told state investigators "I feel like I have been robbed of my life having to live with this."
The hospital was fined $50,000 for its first penalty.
2. At Henry Mayo Newhall Memorial Hospital, Valencia, in Los Angeles County, staff administered three times the prescribed dose of an antibiotic, colistin methanesulfonate, resulting in the patient developing acute renal failure requiring dialysis treatments.
"The Progress notes...disclosed the patient complained of numbness in his face, dry mouth, and saying, 'The antibiotics are killing me,'" according to state documents. A nephrologist's initial impression was that the acute renal failure was caused by hypersensitivity to radiocontrast material during a special X-ray procedure.
According to the state's report, the staff or pharmacy failed to administer the antibiotic in divided doses, and gave a full day's dose in each of three eight-hour segments for several days.
The hospital received a $50,000 penalty for its first incident.
3. At Kaiser Foundation Hospital, South San Francisco, in San Mateo County, staff failed to maintain refrigerators at proper temperatures, and as a result, many medications and vaccine doses stored there were frozen, which is said to reduce their effectiveness.
According to the state's report, some 5,000 patients received either "compromised" pneumococcal vaccines, TB tests, or hepatitis B vaccines. The refrigerator's maintenance checks were scheduled every three years instead of every three months.
Kaiser received a fine of $50,000 for its first penalty.
4. At Los Angeles County+University of Southern California Medical Center, surgeons failed to remove a lap sponge from a patient during an appendectomy. The patient came back to the emergency department complaining of abdominal pain and was diagnosed as having a small bowel obstruction.
When a routine postoperative abdominal radiograph was reviewed, it revealed a drain in the right lower quadrant which was diagnosed as a retained foreign body.
LAC+USC was fined $25,000 for this incident, which is its fifth, but occurred prior to 2009.
5. At Lucile Packard Children's Hospital, Palo Alto, in Santa Clara County, a pharmacy technician failed to dilute ammonium chloride per manufacturer's recommendations, and the supervising pharmacist failed to verify accurate preparation, according to state documents. As a result, a newborn who had just had surgery for a congenital heart defect developed seizures.
The error apparently was provoked because of a shortage of the preferred medication, arginine hydrochloride. A manufacturer's e-mail indicated ammonium chloride could be substituted if diluted. "The pharmacy technician prepared the patient's medication without following the hospital procedure to dilute the medication according to the drug's dilution card," according to the state report.
Lucile Packard was fined $50,000 for its second penalty since 2007.
6. At Mission Hospital Regional Medical Center, Mission Viejo, in Orange County, a surgeon neglected to remove a breakaway tab, which went undetected because, according to state documents, the hospital's count practices did not include these tabs, in violation of its own policy. The patient had to undergo a second general anesthesia for surgery to remove the retained tab.
Mission was fined $100,000. This is the hospital's fourth penalty.
7. At San Francisco General Hospital, in San Francisco County, a patient diagnosed with breast cancer originally signed a consent for a partial mastectomy, but later changed her mind and signed a second consent for a full mastectomy, the state report indicates.
The patient awoke to find that she had undergone a partial mastectomy instead a full one.
The patient recalled that the surgeon "apologized by saying 'At least we didn't do a mastectomy instead of a lumpectomy.' She said, 'I felt so neglected, I was left on a gurney in a hallway for four hours, and I never saw her (Surgeon 1), she never spoke to me..."
The patient told state investigators, "I'm not going back there, I don't trust them," according to the state report.
8. At Santa Barbara Cottage Hospital, in Santa Barbara County, hospital staff failed to prevent a newborn from being abducted from the mother's room, despite both were wearing security bands that sound an alarm if the baby leaves the mother infant unit (MIU).
"A woman wearing scrubs entered the mother's room and told the mother that she was taking Baby A to do footprints," according to state documents. "Baby A's mother agreed to allow the woman to take the baby from the room." A nurse who later entered the room found the baby's bassinet empty and the infant's security band, which was intact, in the bassinet.
"Despite the tamper-proof feature, it was possible for the abductor to remove the band from the baby's ankle intact, and the alarm was not set off."
State officials said the hospital had no security guard on the unit, and the facility "had no access control policy in place, i.e. a defined methodology of who can come, go, and how to limit access to the security-sensitive MIU." Also, state documents indicate that "nurses were utilized as the access control mechanism, but were not adequately trained and when busy could not account for visitors or the security of the unit."
Also, although the hospital had posted MIU visiting hours of 1 p.m. to 8 p.m., "the policy was not enforced. On the date of the abduction, the abductor was on the unit more than three hours before visiting hours were to start and was photographed by surveillance cameras" leaving with a large tote bag, but was not stopped or questioned. Also, the parking structure's attendant was not included in the personnel who were notified of an infant abduction.
"Fortunately, the abductor was unable to pay the parking fees before leaving the lot," and so the attendant noted the abductor's name and license plate number, which was used to locate the abductor and the baby later that evening. The hospital was fined $50,000. This was Santa Barbara Cottage's first penalty.
9. At Scripps Memorial Hospital, La Jolla, in San Diego County, a spine surgeon failed to remove a 2.5 cm temporary pin, and a fluoroscopy test prior to the patient leaving the operating room and two more X-rays failed to discover it. "According to the radiologists, they both believed the object to be part of the surgical hardware. The radiologists explained that many different types of procedures with many different types of hardware are performed at the facility."
Even though they noted the object in their review, they did not notify the surgeon "because they did not perceive the object as foreign but thought perhaps it was an unusual variant," according to state documents.
The patient "complained of discomfort throughout the evening following surgery," according to the state report. She "complained of feeling something stuck in her throat at 8:35 p.m., something moving in her neck at 9:30 p.m., and finally difficulty breathing at 10 p.m.," when the surgeon was notified and another X-ray was ordered, finally revealing the pin. The patient developed difficulty swallowing and hoarseness, but eventually recovered and was discharged.
Scripps was fined $100,000 because this incident was its sixth penalty.
10. At St. Jude Medical Center, Fullerton, in Orange County, a registered nurse who had not completed her three-month orientation misunderstood a physician to say that a patient required a morphine dose up to 20 mg. per hour intravenously, when the physician had merely ordered 2 mg. per hour—one-tenth the dose.
"The patient died within an hour of the morphine dose increase," according to the state's report. "The coroner's autopsy report revealed a blood level of morphine of 4.1 milligrams/liter and the corner determined the cause of death was due to 'acute morphine intoxication.'" According to the state's report, the hospital's administrative document indicated the nurse "admitted she did not know how to program a PCA (patient-controlled analgesia infusion) pump but did so anyway."
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.