A physician who lacked privileges to perform nephrectomies took out the wrong kidney at a Riverside hospital. A newborn required intubation after receiving IV morphine sulfate intended for the mother in Mission Viejo. And a gero-psychiatric patient suffered a brain bleed and died after his recliner, which lacked crossbars, fell backwards in Poway.
Those three incidents are among 10 that resulted in "immediate jeopardy" to patients, with fines totaling $550,000, in the latest round of penalties against nine California hospitals, state health officials announced yesterday.
Since the law requiring such penalties took effect in January 2007, the state has made 11 announcements of 156 fines totaling $4.8 million against more than 108 hospitals, about one-fourth of the acute care facilities in the state.
Kathleen Billingsley, deputy director for the state's Center for Healthcare Quality, says the publicity about the penalties, unique to California, has helped foster a culture of improving hospital safety.
"These administrative penalties, the press releases that come with them and the publicity results in driving lots of changes," she says. "Every CEO has focused on what they need to do to address these issues, and now, with this 11th release, and they have indicated to me that they don't want to be the hospital that has one of these. They want to be the hospital that solves the problem."
Billingsley adds that she sees hospitals being more transparent about the incidents. "They're talking to the community, saying, ‘Yes, this happened' and they're getting dialogue going to what they're doing to prevent it from happening again. We're starting to see more and more change driven through the hospital community as a result of these."
Money from the fines will be used to conduct studies to find solutions to the most frequently recurring mistakes. One project slated to receive $800,000 will seek ways to avoid surgical teams forgetting to remove tools or sponges during the procedure. Nearly one in five fines issued was due to a retained foreign object, she says.
State law allows public health officials to levy fines between $25,000 for healthcare safety lapses in hospitals that occurred prior to 2009. For those errors since 2009, the penalties are $50,000 for the first violation, $75,000 for the second, and $100,000 for the third or subsequent violation at the same hospital.
The following hospital fines were announced yesterday:
Scripps Green in La Jolla, San Diego County, received two fines, of $50,000 and $75,000. The first resulted because in May 2009, a Scripps physician who was not trained in the use of what was termed a "tricky" lumbar catheter drain, penetrated a patient's spinal column with the wrong end. A 3.5 centimeter tip of the catheter was sheared off during the removal and remained in the patient's ligaments.
The second Scripps fine resulted from the use of equipment between August 1, 2008 and July 31, 2009, potentially exposing 12 surgical hip/fracture patients to blood borne pathogens including HIV and hepatitis. According to the state document, a specialized surgical screwdriver was not disassembled for proper cleaning. Sterile processing department staff "were not aware the sheath came off the screwdriver," according to the state's deficiency report.
Scripps officials issued a one-page statement saying that the patient in the first case was not harmed, but added that it may appeal the second fine, on advice of legal counsel, because the "device manufacturer failed to provide proper in-service education to SPD staff—who were unaware the equipment came apart."
Since 2007, Scripps has received four fines, the second-highest number of financial penalties assessed one hospital.
At Parkview Community Hospital in Riverside, Riverside County, multiple errors resulted in a surgeon performing a radical nephrectomy last July on a patient's right kidney instead of the left. Not only did the doctor not have staff privileges to perform kidney surgery at the time, but the Spanish speaking-patient was not given an opportunity to give full informed consent for the procedure.
"There was no documented evidence that Patient A was provided information about his diseased left kidney, options, use of anesthesia or possible risks and complications by a staff member. There was no documentation found to indicate a Spanish-speaking clinician reviewed the consent Patient A signed for a right radical nephrectomy," the state said.
"This failed practice potentially led to Patient A's mistakenly signing a consent for removal of the incorrect (right) kidney," the state document says.
As a result of the errors, the patient now must undergo dialysis two to three times a week for four hours at a time, the report said.
In a news conference yesterday, Billingsley said that the state does require hospitals to provide competent translation services for patients and family members to communicate with providers.
"Obviously, we're a multicultural state, and this service is paramount to the delivery of healthcare in California."
At Tri-City Medical Center in Oceanside, San Diego County, oxygen that was passing around the edges of a mask on a patient during surgery in September "leaked onto the operative site and was ignited by the electrocautery, (a surgical device that uses electrical current to cause tissue destruction) causing a flash fire. The fire lit up the sterile drapes and Patient A sustained burns to his face and singeing to the hair."
The state document says, "Patient A sat up (under local anesthesia) after the fire started. The OR staff extinguished the fire with water and patting the drapes." According to a plastic surgeon subsequently called in to evaluate the patient's injury, the patient sustained first- and second-degree burns on the face, chin, cheeks, ears, and forehead and the eyelashes were singed.
The fine is the second one for Tri-City.
Hospital COO Casey Fatch said, "We regret this occurrence and take our commitment to ensure the safety and quality of care of our patients and their families seriously." She said preventive measures have been put in place.
Another incident involving a fire occurred at Hi-Desert Medical Center, Joshua Tree, San Bernardino County, resulting in second degree burns to the back of a 4-year old undergoing a tonsillectomy last June.
When the patient wet the bed, a nurse inserted cloth padding on the spot, but the padding interfered with the grounding system used for the surgical cautery machine. "Heat in the presence or absence of acidic urine resulted in partial thickness chemical burns," according to Hi-Desert's Adverse Event Report, the state document says.
At Rady Children's Hospital in San Diego, San Diego County, a 3-year-old with cerebral palsy was given 89.5% phenol solution when the physician had ordered 5%, 2.5% in each leg in March 2009. When diluted, the toxic carbolic acid medication relieves muscle spasms and is supposed to be administered intramuscularly.
"Even though the 2 oz. bottle of phenol solution was clearly labeled with a much higher concentration, pharmacist S failed to identify that the prepared phenol solution was not what Physician M ordered," the state document says. Physician M "administered 2.5 ml of 89.5% phenol instead of 5% into each of Patient K's thighs" 17.9 times the concentration ordered, resulting in "inflammation and fluid build-up" in the patient's thigh muscles, which could have caused necrosis or cell death.
At Pomerado Hospital in Poway, San Diego County, last June, a patient with dementia in the facility's gero-psychiatric unit "was found by the licensed nursing staff in his room in a hospital style recliner chair that had fallen over backwards." A "personal alarm" system was not present, and there was no documentation in the medical record that the physician was notified of the incident.
According to the state document, inspection of chairs, one of which he used, "revealed that the cross bars . . . under the footrest were not intact."
Subsequent tests and autopsy showed the patient had developed bleeding in both the right and left sides of the brain "secondary to the fall" and "a result of blunt head trauma" and was transferred to an intensive care unit and later moved to a facility where the patient died.
This is the second fine against Pomerado since 2007. A hospital spokesman said that the staff extends sympathies to the patient's family, but may appeal the fine.
In Mission Hospital Regional Medical Center in Mission Viejo, Orange County, a newborn in April 2009 "became dusky, exhibited respiratory depression and required intubation" after receiving morphine sulfate injection intended for the mother. The baby was bonding "skin to skin" with the mother at the time.
State officials interviewed neonatal intensive care unit staff who said "it is thought the nurse might have injected the MS into the baby's running IV instead of the mother's."
Mission Hospital issued a statement saying it "is deeply concerned" about the incident and has "conducted a process review and provided ongoing education and training for our patient care teams with regard to administering medications."
At Alameda County Medical Center in Oakland, Alameda County, a patient died last October after staff "pushed" an IV dose of Dilantin in 5 minutes instead of over the course of an hour, as prescribed. Dilantin, used to prevent and manage seizures, has precautions for "hypotension and bradycardia, cardiac arrhythmias and cardiovascular collapse (especially with rapid IV use)," ultimately the cause of death for the patient.
The nurse "failed to recognize that the maximum rate of IV administration of Dilantin was 50 mg per minute," the state document said. This is Alameda's second administrative penalty.
At Marin General Hospital in Greenbrae, Marin County, a surgical team left a piece of laparoscopy tape sponge inside an obese patient during a Cesarean section last October. The tape was not discovered until three days later.
"The surgeon, the scrub technician, and the circulating nurse stated that there was confusion prior to closure, and the staff thought the last sponge was on the operative field," the state report said. Additionally, the patient's medical record did not include any mention of the retained foreign body or the exploratory laparotomy to remove it.
In a statement, Marin officials apologized for the incident and said they have implemented a monitoring system and are reeducating staff to make sure that nurses and physicians work collaboratively in tracking sponges.