13 Hospitals Fined for Mishaps, Never Events

California has imposed its sixth round of fines against hospitals for serious mishaps and so-called never events, such as fatal errors with high-risk medications, surgery on the wrong patient and three cases in which objects were left inside patients during surgery.

One hospital was fined for not promptly investigating an alleged sexual assault by a staff member against a patient.
Other reasons for the punitive actions by the California Department of Public Health, which licenses about 450 acute care facilities throughout the state, were failure to properly transfuse a patient and the incorrect use of respiratory equipment.

Administrative penalties of $25,000 were assessed on the facilities for events occurring in 2008.  Incidents that occur after Jan. 1, 2009 will be fined $50,000.

These penalties will bring $350,000 to the state to implement better safety strategies in acute healthcare settings. Since the law allowing hospitals to be assessed a monetary fine took effect in 2007, 87 fines have been levied against 59 hospitals, for a total of $2.175 million, said department director, Kathleen Billingsley.

About $1.2 million has so far been collected. However, 18 of the hospitals are still appealing their fines.

Billingsley said that far from just "showcasing" hospitals that made serious errors, the public announcements of these penalties prompts all hospitals to improve. "The hospitals go back and say 'Wait a minute. Do we have a process to prevent this from happening here?'" she said.

As a result of knowing how things go wrong, "the best practices are being developed and have been developed."  Much of the time, she added, "it's a process breakdown" which prompts the hospitals "to put in additional checks and balances to make sure something like it doesn't happen again."

The state is using the fines to fund safety and error prevention programs. Billingsley's department is in the process of analyzing the errors and their underlying causes, and will at some point issue a report.

The hospitals assessed fines in this announcement include Brotman Medical Center, Hollywood Presbyterian Medical Center, Harbor-UCLA Medical Center, Saint Francis Medical Center, and Whittier Hospital Medical Center in Los Angeles County; St. Jude Medical Center, University of California Irvine Medical Center in Orange County, which received two fines; and University of California San Diego Medical Center and Scripps Mercy Hospital in San Diego County.

Fines were also levied on Clovis Community Medical Center and St. Agnes Medical Center in Fresno County, John Muir Medical Center in Contra Costa County, and the University of California San Francisco Medical Center in San Francisco County.

The specifics problems were:

1. At Whittier Hospital  Medical Center in Los Angeles, the wrong patient was taken for surgery a dilation and curettage procedure, resulting in the operation being initiated in a 63-year-old patient with colon cancer, who was scheduled for a Port-a-Cath device for chemotherapy. The operation "was terminated when found that the patient did not have a uterus." The arm-band was not checked, the "time-out" was described as "quick," and there was no documentation that correct side/site checks were performed. Also the patient had been put to sleep prior to the "time out," contrary to anesthesia protocols.


2. At Brotman Medical Center in Culver City, a patient received hydromorphone by intravenous push rather than subcutaneously as prescribed, resulting in the patient going in to a coma and requiring mechanical ventilation. The patient had been admitted to the hospital for a colon resection. An investigation determined that hydromorphone syringes were improperly labeled and their administration in at least two patients was not independently verified by a second nurse, as hospital policy requires.


3. At Clovis Community Medical Center near Fresno, lack of communication between two physicians and the failure to check an INR (international normalized ratio) test for a patient resulted in potentially adverse effects from the anti-clotting drug warfarin, which conflicted with amiodarone, another drug the patient was taking.


4. At Hollywood Presbyterian Medical Center in Los Angeles, a patient received the wrong blood type because a staff member went to the wrong patient's room. The error caused a dangerous hemolytic reaction that resulted in the patient's death.


5. At John Muir Medical Center in Concord, the failure to properly restrain a patient for a radiology exam resulted in a fall that caused a ruptured right eyeball. The result was that the patient became blind in that eye.


6. At Los Angeles County Harbor UCLA Medical Center, a surgical sponge was left in a patient for more than 10 months, despite the patient complaining of pain, nausea, and vomiting. Another surgery was required to remove the sponge and a cyst that had formed around it.


7. At Saint Agnes Medical Center in Fresno, the facility's third such penalty, was assessed after a patient died following surgery because staff did not intervene quickly enough to remedy her abdominal hemorrhaging after a hysterectomy.  


8. At St. Francis Medical Center in Lynwood, potassium levels weren't monitored in two patients resulting in cardiac emergency. One of the two patients died.


9. At St. Jude Medical Center in Fullerton, a plastic drape or towel used to guard a sterile field was repositioned by the surgeon to retract the patient's bowel and subsequently became hidden in the patient's body cavity. The drape was not counted like other devices, such as sponges or surgical tools. "After the patient went to the recovery room Surgeon D called Nurse B to ask 'did we remove the drape?' Nurse B stated she told the surgeon she did not remember the drape being removed," the statement of deficiency says. Removing the drape required a second surgery requiring intubation, that carried additional risk of respiratory problems, increased blood pressure or heart rate, damaged teeth, lips and swelling, or injury to the throat or larynx.


10. At Scripps Mercy Hospital in San Diego, faulty respiratory equipment was used to provide ventilation support to a trauma patient with a brain injury on Sept. 1.  Also, the hospital failed to make sure that the patient's respiratory status was checked by a licensed nurse and respiratory therapist during transport of the patient to a portable MRI unit located outside the facility. When the patient was administered vecuronium and sedated for the MRI, the patient went into respiratory and cardiac arrest. An investigation determined that the transport ventilator lacked the "on/off" knob and the "pressure relief knob and had not been maintained since April."


11. At the University of California Irvine Medical Center, hospital officials failed to promptly investigate an incident involving a patient's complaint that she was sexually abused by a staff member. "The facility failed to ensure the safety of other patients by allowing the alleged abuser continued contact with other patients after the reported allegation," the state's record says.


12. At the University of California Irvine Medical Center, staff failed to watch a patient at risk for falling, who subsequently got out of bed and fell, sustaining a fatal laceration to the back of the head. The laceration was so severe that the patient's blood pressure subsequently dropped, he lost consciousness, which he did not regain. Staff also failed to take precautions, such as making sure that a walker was left in the room for the patient's use or that non-skid socks were on his feet.


13. At the University of California San Diego Medical Center, surgeons operating on a patient for lumbar stenosis left a Raytec (x-ray detectible) surgical sponge in her spine area, which wasn't discovered for three months. The facility failed to follow its own procedures, which required that post-surgical x-rays be taken to make sure all foreign objects had been removed.  A second surgery was required to remove the sponge.


14. At the University of California San Francisco, failure to establish safety standards for administering Flolan, a drug that opens up blood vessels in the lung in patients with pulmonary hypertension. The mishap resulted in a patient receiving 23 times the prescribed dose, which proved fatal.  The infusion device did not meet manufacturer's recommendations and one registered nurse with no validated competency in using the device was assigned to provide the patient's care.