Medical Errors at 10 CA Hospitals Draw Fines of $625K

Cheryl Clark, August 21, 2013

California's latest round of penalties for hospital blunders that resulted in patient harm or death includes a wrong-site surgery, feeding errors, a retained surgical object, and a number of unnecessary "emergency" coronary interventions.

Medical Errors

Slideshow: Medical Errors at 10 CA Hospitals
Draw Fines of $625K

An unapproved fecal transplant research experiment in end-stage brain cancer patients in Davis, a 'time out' lapse resulting in an incision to the wrong testicle in San Diego, and a failure to connect a ventilator in Greenbrae are among the latest round of immediate jeopardy penalties for 10 California hospitals.

"In issuing these administrative penalties, our goal… is to improve the quality of healthcare in all California hospitals," Debby Rogers, deputy director for the state Department of Public Health's Center for Healthcare Quality, said at a news briefing to announce the fines last week.  

"Information on incidents that led to the penalties will be used to determine how violations and deficiencies can decrease and be eliminated over time."

The department issues penalties to hospitals about four times a year. The fines are $50,000, $75,000, or $100,000 per incident, depending on whether the penalty is the hospital's first, second, or third within the last three years.

The errors, which resulted in death or other forms of harm to hospitalized patients, are as follows:

1. At the University of California Davis Medical Center, Davis, in Sacramento County, two neurosurgeons harmed three patients diagnosed with end stage glioblastoma multiforme, an aggressive brain tumor, when they experimentally implanted fecal bacteria into their brains without approvals.

According to state documents, the hospital staff and physicians failed to verify staff compliance with research safety and approval protocols, failed to follow acceptable standards of pre, intra, and post-operative surgical care, and failed to comprehensively investigate the infections that resulted from the implants, although the incidents "met the hospital's written criteria for adverse and sentinel events."

The implantation of gastrointestinal tract bacteria into the brain was intended to "create a wound infection that would attack tumor cells," the report said. But the material "had never been tested in humans" nor had the experiment received required approvals from the U.S. Food and Drug Administration or an Institutional Review Board.

The neurosurgeons and hospital staff also didn't inform the hospital's investigational pharmacy of their plans and did not properly label the material before it was taken into the operating room.


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