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Immediate Jeopardy Fines for 12 California Hospitals

A 29-year-old patient who entered a Kaiser Foundation hospital in Oakland to  have a facial birthmark removed died of an arterial embolism because her doctor  didn’t read the operating instructions for the laser device he tried to use.

A patient admitted to a Sutter hospital in Crescent City to remove a basal cell  carcinoma suffered burns on her face, chest, and ear when the surgeon let the  oxygen mask on her face get too close to a cautery device, which started a  fire.

And at a Kaiser Foundation hospital in San Diego, a surgeon removed the wrong  kidney in an 85-year-old man. The surgeon told investigators that he did not  have radiology images in the operating suite because he “did not  feel” they “were relevant to this case.”

These departures from safe practice, all of which occurred in 2010 or 2011, are  among 12 incidents warranting “immediate jeopardy” penalties, which California  health officials levied Thursday to 10 hospitals. Two hospitals received  penalties for two such incidents. In all, four patients died from these errors  and several others were seriously hurt.

California law established in 2007 calls for such hospitals to be penalized  with fines of $50,000, $75,000 or $100,000, depending on the frequency of violations.  Fines against small, rural hospitals may be lower.

The penalties are designed to prompt  hospitals “to  be successful in their efforts to reduce hospital-acquired infections, decrease  medication errors, eliminate surgical errors, and prevent other adverse  events,” Debby Rogers, deputy  director of the Center for Health Care Quality for the California Department of  Public Health, said during a news briefing to announce the latest $785,000  worth of fines.

“The  value of the fines is in bringing awareness both to the healthcare industry and  healthcare providers, but also to consumers and patients who can then take this  information to have a conversation with their healthcare providers, to better  understand the safeguards that each facility and each provider would put into  place to prevent these types of events,” she said.

To date, 141 of the state’s 450 acute care hospitals have received 254 fines  totaling nearly $10.4 million, $7.6 million of which has been collected.
According to state documents, which  can be found on the state website by county, these are some details of each incident:

1. At Kaiser Foundation Hospital,  Oakland, Alameda County, a healthy 29-year-old woman was having a congenital  birthmark removed from her upper lip. The physician used a Sharplan laser with  helium. But as soon as the laser wand was activated near the birthmark, “the  patient’s face and neck began to swell up ‘secondary to the helium gas of the  laser device,'” trapping air. The patient’s blood pressure began to fall  and a code blue resuscitation was unsuccessful. State investigators said that the ear-nose-throat (ENT) specialist failed to read  or follow extensive warnings in the device’s 30-page manual that specifically  instructed proper laser positioning to avoid a gas embolism. Hospital policy  regarding privileges for the ENT department “is not per device but rather  per condition or anatomic location” and “lasers are not part of the  checking process that the operating room manager does.” The physician involved told investigators he didn’t realize the device’s high  pressure, and said “I did not read the manual (with instructions for  use.)” The penalty is $100,000. This is the hospital’s third penalty.

2. At Kaiser Foundation Hospital,  San Diego County, an 85-year-old man admitted for surgery to remove his left  kidney, which had a mass, instead woke up without his right one.  The surgical suite did not have the patient’s radiology images, which could  have prompted the surgery team to catch the mistake, because the surgeon did  not think they “were relevant to this case because the procedure did not  require a review of the anatomy or vasculature.” The case was complicated by the fact that the patient himself “pointed  to” the right, incorrect, kidney, misidentifying the one that was  diseased, and the surgical team didn’t independently check. The error was discovered only after the pathologist told the surgeon that there  was no mass in the removed kidney submitted for testing. The patient became  tearful in describing the incident to state investigators, saying he now suffers  “chronic fatigue,” is unable to “perform his previously enjoyed  hobbies of dancing and golfing,” and is solely dependent on his wife and  other family members. The penalty is $75,000. This is the hospital’s second penalty.

3. At Kaiser Foundation Hospital,  San Rafael, Marin County, surgeons neglected to remove a 3- or 4-inch piece of  iodoform- impregnated gauze. The epigastric procedure required three separate  sterile instrument and supply table set ups, and multiple technicians and a  surgeon, none of whom remembered the gauze being used during the procedure. The retained gauze was discovered five weeks after the patient’s surgery when  she felt pain in her abdomen and went to see a doctor. “Physician B. thought an incision on her abdomen was infected by a stitch  underneath the skin,” says the state report. The patient stated “that  the physician opened up the incision and pulled a long strip of gauze out of  her abdominal area.” A member of the surgical staff told investigators that the hospital’s surgical  object count policy required a count of sponges, needles and sharps, but was  not specific about other items such as gauze. The penalty is $50,000. This is the hospital’s first penalty.

4. At Kaiser Foundation Hospital-South  Bay, Harbor City, Los Angeles County, a patient admitted to repair his  gastrointestinal tract bled to death when he received the anticoagulant  Activase instead of the coagulation drug Activated Factor VII, which the  surgeon requested.
A certified registered nurse anesthetist told investigators he was handed a  bottle of medication by another physician and “put his trust in (my)  supervisor and took the bottle of medication and administered the drug.” He said he “assumed it was the correct medication.” The other  physician who gave him the drug said he “did not read the medication label  and did not verify the medication name.” State investigators said, “unfortunately, he did not do what he commonly  practiced.” The penalty is $50,000. This is the hospital’s first penalty.

5. At Kaweah Delta Medical Center,  Visalia, Tulare County, two physicians neglected to rescue a woman who began  bleeding profusely after a laceration during birth, and ultimately died from  loss of blood. The doctors failed to call for expert backup, and delayed a request for the  rapid response team, as the woman bled for more than an hour. One of the physicians, identified as “MD 2,” told investigators  “she did not keep track of the amounts of fluid and/or blood loss, vital  signs, amount of urine output, and the amount of fluids given. When asked what  she would have done differently, MD 2 stated, in retrospect, she should have  called for assistance. The penalty is $50,000. This is the hospital’s first penalty.

6. In a second incident at Kaweah Delta Medical Center, Visalia,  Tulare County, a patient died after being admitted with abdominal pain and  underwent removal of the pancreas, which can lead to irregular glucose levels,  diabetes, and mal-absorption of food.
After parenteral nutrition was stopped, physicians apparently neglected to adequately  check glucose levels, and the patient went into a hypoglycemic coma, which was  mistaken for a stroke.  The rapid response team was called but was not given information about the  patient’s pancreas removal. The team informed the family that the patient had a  stroke, but no providers had checked the ordered CT.
The family was notified and informed that “death is imminent,” and  thus patient’s code status was changed to “do not resuscitate.”
“The facility failed to recognize the need to taper the TPN (parenteral  nutrition), monitor blood glucose levels after the TPN was stopped, failed to  assess, develop, and implement appropriate interventions, failed to pass on  correct information due to a wrong assessment, the (rapid response team) failed  to get sufficient Patient history for a proper assessment, and there was no  advocacy for the patient from the (response team) to activate the team, and  resulted in the death of the patient.” The penalty is $75,000. This is the hospital’s second penalty.

7. At Methodist Hospital of  Southern California, Arcadia, Los Angeles, surgeons neglected to remove a  sponge from a patient who was admitted for removal of the gallbladder. Investigators said that the patient “returned to the facility five  different times after his discharge home with the complaint of chest pain,  headache, and not able to urinate,” and was ultimately readmitted when a  radiology report indicated “a foreign body reaction or abscess,” which  required another surgical procedure to remove it. Staff told investigators that the counts of all the surgical items used were  “correct.” The penalty is $50,000. This is the hospital’s first penalty.

8. At Mission Hospital Regional Medical Center, Mission Viejo, Orange  County, an apparently hurried operating room schedule resulted in surgeons  failing to remove a surgical sponge from a patient admitted for a coronary  artery bypass operation. A clinical coordinator told investigators that “the operating room staff  had felt ‘pressured’ because the next case was due and the final count was done  prematurely before the cavity was closed.” Also, the nurse had documented the initial, additional, and final sponge counts  as “correct.” The penalty is $100,000. This is the hospital’s fifth penalty.

9. Also at Mission Hospital Regional  Medical Center, Mission Viejo, Orange County, surgeons operated on the  wrong part of a scoliosis patient’s spine. Although an X-ray was available to  mark the site for surgery, “however, there were no films in the operating  room during the surgery,” the facility’s risk manager told investigators.  Also, the surgeon “had not marked the skin at the surgical site  preoperatively and had not read the radiologist’s report of the post-operative X-ray  of the spine.”  The penalty is $100,000. This is the hospital’s sixth penalty.

10. At Orange Coast Memorial Medical Center, Fountain Valley, Orange  County, a C-section patient had to undergo a second surgery to remove a  retained sponge, made more complicated because the patient developed an abscess  and bowel perforation, necessitating an eight-day hospitalization. The penalty is $50,000. This is the hospital’s first penalty.

11. At Sutter Coast Hospital, Crescent  City, Del Norte County, a patient admitted for removal of a basal cell  carcinoma on her forehead received second-degree burns on the face, chest, and an  ear after the oxygen mask on her face caught fire when the doctor’s cautery  device came too close. The patient “stated that her lips were all scarred after the incident and  that two of the scars were permanent,” investigators said. The incident  required two days in the intensive care unit, and the patient “now has  trouble with her mouth, stated that she looked like a fish, and it was hard to  put her dentures in the right way.” The penalty is $10,000, reduced under a provision of state law that allows  lower penalties for small, rural hospitals. This is the hospital’s first penalty.

12. At UCSF Medical Center, San  Francisco County, the hospital team failed to make sure that a patient did not  have an allergy to antibiotics before giving her amoxicillin. Her severe  anaphylactic reaction required stabilization in the intensive care unit on a  ventilator and acute hemodialysis, and then on an inpatient unit for 21 days.  Formerly independent and able to bathe, ambulate, and dress herself on her own,  the woman subsequently was discharged to a skilled nursing facility,  investigators wrote. The penalty is $75,000. This is the hospital’s sixth penalty.


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