California health officials yesterday issued another 11 monetary fines to hospitals where staff made harmful and avoidable mistakes.
The latest report of hospital mistakes includes $25,000 fines per facility for placing patients in immediate jeopardy or actually causing them serious injury or death. In at least three of the 11 hospitals, the incidents led to the patient's death.
The mistakes included:
- The placement of a pathology report in the wrong patient's chart resulted in a Los Angeles man undergoing a leg amputation for cancer he never had. The surgeon never received the patient's corrected file, according to the report.
- The face of a Santa Monica patient undergoing an eyelid blepharoplasty procedure reportedly caught fire after someone used excessively high settings on a cauterization device, resulting in second and third degree burns and a transfer to another hospital's burn unit.
- Six hospitals from Chula Vista in San Diego County to Fortuna in Humboldt County left a clamp, hemostats, towels or sponges or a quarter-sized ring sizer inside patients, requiring all of them to undergo repeat surgery to remove them. In one case, a guide wire that was left by Mendocino physician in a heart procedure migrated up to the patient's neck, requiring an emergency transfer to another hospital's catheterization lab to remove it, according to the state.
Kathleen Billingsley, deputy director for the California Department of Public Health, said the 11 new fines bring the total of 115 monetary penalties against 80 hospitals to $2.87 million under a law that took effect Jan. 1, 2007. She has made public announcements about other batches of fines seven times previously, most recently Sept. 3.
The funds will pay for efforts to determine root causes of such mistakes as well as help hospitals implement strategies for avoiding them.
Of the $2.87 million, $1.6 million has been collected for 75 of the 115 fines. The others are on appeal, or have recently been issued and the 10-day appeal deadline has not yet passed.
The 11 incidents occurred in 2007 or 2008, but Billingsley says that assessing a fine "reflects a thoughtful process [and] is not something we treat lightly. We clearly recognize the importance of this in terms of its enforcement, but also its impact on the hospitals. We're very careful to make sure that the event corresponds with state law regarding the definition of immediate jeopardy."
So far, about 32% of the fines have been levied against hospitals for making avoidable medication errors or pharmacy mistakes. Another 19% were levied for leaving foreign objects inside patients during surgery.
Also, 19% involved patient care issues, 7% were caused by equipment failures, 3.5% were the result of patient abuse, 2.6% improper food handling, 2.6% problems with staffing or training, 1.8% were caused by diagnostic or lab tests errors, and .9% involved surgical errors.
The latest batch of fines included the following incidents:
1. At USC University Hospital in Los Angeles, Los Angeles County, which was owned by Tenet at the time, a patient hospitalized after a leg fracture agreed to a leg amputation after his surgeon reportedly told him incorrectly that the pathology report of the biopsy said he had B-cell lymphoma. In fact, the pathologist had placed another patient's pathology report in the hospitalized patient's chart, according to the state.
Though the mistake was corrected in the lab's electronic system a few moments after it was placed, the hospital reportedly failed to communicate the mistake to the surgeon that there was a change in the record. "There was no indication that any verbal or other communication was made to the physician of record, or to interested parties, alerting them to the change in diagnosis," according to the report.
Part of the problem was that the facility's computerized chart system listed records in reverse chronological order, so the newest report went to the bottom and the oldest report went to the top of the patient's file.
The state added that Tenet Health officials failed to report the incident to state officials as the law requires, and as a result were fined $30,300, an amount they have not yet paid, according to state documents. Records show Tenet has appealed the fine.
2. At Saint John's Hospital and Health Center, Santa Monica, in Los Angeles County, an electrocautery device that was supposed to be operated with the lowest possible setting was reportedly turned up to 10 watts. The blepharoplasty patient sustained second- and third-degree buns to the face, lips, nasal passage, and left eye, and was transferred to the intensive care unit. The patient was subsequently taken to a burn unit for debridement and autografting. Documents say, "a spontaneous fire broke out onto (the patient's) face from the bovie tip and the oxygen mask."
3. At Sharp Chula Vista Medical Center, Chula Vista, in San Diego County, surgical teams allegedly left a bulldog clamp inside a patient undergoing cardiac bypass surgery. According to state documents, staff disagreed about whether four or five clamps had been used in the patient. An x-ray to locate a missing clamp was unsuccessful, apparently because of confusion as to what the technician and radiologist were looking for, said the state.
The O.R. manager said the staff "did everything possible but the heart was a thick muscle and it could be hard to see behind it even with an X-ray." The clamp was finally removed 10 days later after it was identified by a chest CT.
4. At Coast Plaza Doctors Hospital in Norwalk, Los Angeles County, reports show that surgeons allegedly failed to remove two surgical clamps called hemostats used for constricting blood vessels from a patient's abdomen. Documents say that the surgical team reported that the instruments were correct. Seventeen days later, the patient came to the emergency room in abdominal pain, when an X-ray discovered the clamps. The patient underwent surgery to remove them.
5. At Alta Bates Summit Medical Center, Summit in Oakland, in Alameda County, a quarter-sized ring/band sizer used during heart valve repair was allegedly left in a patient's pericardial sac and "a major chest surgery was required to remove it. After the chest surgery, (the patient) experienced complications [that included] kidney failure." The patient's post-operative course was complicated by pooled blood that also required surgery, but it wasn't until 11 days later that a CT scan detected the sizer.
6. At Loma Linda University Medical Center in Loma Linda, in San Bernardino County, surgeons reportedly left a surgical sponge inside a patient undergoing a liver transplant. The patient had to undergo an additional surgery to retrieve the sponge about 12 hours later. The incident investigation revealed problems with the hospital's system for accounting for counts for items used during surgery, an accounting that is not placed in the patient's medical record. This is the second penalty; the first was for a potentially fatal medication overdose, according to the state.
7. At Los Angeles County University of Southern California, Los Angeles, surgeons allegedly neglected to remove two laparotomy towels and three laparotomy sponges from a gunshot patient who underwent surgery to remove the bullet.
Hospital officials reported that counts of all materials used during the procedure were correct. X-rays to detect foreign surgical objects were negative. Even the use of a fluoroscopy failed to detect the items. The items were finally detected after the patient developed a fever and rapid heart beat, and another bullet was suspected as causing the infection. After a CT scan located the towels and sponges, the patient underwent surgery for removal. This is the third penalty against LAC/USC, said the state.
8. At Redwood Memorial Hospital in Fortuna, in Humboldt County, a guideware used during cardiac catheterization, which was reportedly left inside the patient, migrated up to the patient's neck. It required an emergent transfer of the patient to another acute care hospital's catheterization lab for a second procedure to immediately remove the guide wire. "These failures placed (the patient) at potential risk for complications, internal injuries and/or death from the migrated guide wire." The involved physician allegedly told state investigators, "I spaced out and it was a regrettable incident," said the state.
9. At Mendocino Coast District Hospital, Fort Bragg, in Mendocino County, a staff nurse who was allegedly no longer qualified to conduct fetal heart rate for a woman in labor incorrectly wrote that the fetus had a 140 to 150 beat per minute heart rate.
The patient, who was giving birth, had adequately dilated and was taken to delivery but the baby was stillborn. "Review of documents . . . led to the conclusion that the staff nurse had applied the monitor incorrectly and the monitor was recording the mother's heart beat rather than the baby's. The staff nurse who was appropriately qualified was reportedly busy with another patient," said the state.
10. At Tri-City Medical Center, Oceanside, in San Diego County, a 91-year-old patient with dementia died after sustaining a femoral fracture when she fell out of bed. Documents reveal that fall precautions were ordered, but a pressure alarm was not turned on and although the patient was wearing a Posey vest, it was not attached to the bed, said the state.
11. At Kindred Hospital in Ontario, in San Bernardino County, staff failed to observe physician's orders to have a one-to-one sitter to prevent an agitated brain injury patient from pulling out a tracheostomy tube, IV lines, and feeding tubes. "There was no documentation that there was a one-to-one sitter in the room." That "resulted in (the) patient pulling out his tracheostomy tube . . . and suffering cardiac and respiratory arrest, and subsequently expiring," noted the state.