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.