The California Department of Public Health (CDPH) announced last week that it had fined eight hospitals a total of $775,000 for 10 incidents, and like the list released last October, it included safety violations that resulted in serious injury and death.
Fines ranging from $50,000 to $100,000 were meted out to medical centers in five counties for incidents including the improper mixing of medications and surgical materials left behind in a patient.
Some of the cases date back to 2012, but have only recently been closed.
Desert Regional Medical Center in Palm Springs–A 38-year-old female had a Cesarean section for a baby that insisted on coming out feet first. She complained to her physician of abdominal pain (pdf) during her six-week follow-up appointment. Surgery turned up an errant sponge and a host of related medical problems related to hosting a foreign object in one’s body. The hospital was dinged for not counting sponges. $100,000
Kaiser Foundation Hospital in Anaheim–The patient died (pdf) after being admitted with symptoms of stroke and being treated with two drugs that don’t play nicely together under the circumstances. The attending physician said he chose the aggressive therapy, knowing of the policy against using the drugs within 24 hours of each other. $50,000
Kaiser Foundation Hospital in Riverside–A 2009 hysterectomy was complicated (pdf) by the failure to remove a metal object from the patient until after a year and a half of bleeding and pain during intercourse. $50,000
Memorial Hospital Medical Center in Modesto–A female patient (pdf) was admitted for removal of an ovarian cyst. Two months later she was back in another hospital to have a sponge and a chunk of her eroded small bowel taken out. Records and interviews indicated three separate sponge counts were conducted during the first operation. Something didn’t add up. $100,000
Sharp Memorial Hospital in San Diego–A 73-year-old woman admitted with abdominal pains fractured her back after falling off a surgical table while being administered a catheter in her arm. A nurse said the woman had not been secured to the table with straps because she was too fat (pdf). Investigators suggested the procedure should have been performed in a room equipped to handle someone her size. $100,000
Southwest Healthcare in Murrieta, Riverside County–A patient over the age of 65 fell out of bed (pdf) and, in response to questions if she hit her head, responded that she had hurt her thigh. Indeed, she had. Surgery ensued, rod was inserted and the patient was returned to bed, where she died of a brain hemorrhage and cranial trauma five days later. Investigators said the dazed patient, who had already demonstrated she would not stay in bed, should have been better restrained. $100,000
Southwest Healthcare in Murrieta, Riverside County–A surgical team left gauze inside a patient (pdf) receiving a pacemaker. The patient underwent two subsequent procedures to removed the gauze and have a new pacemaker installed. $100,000
St. Mary Medical Center in Apple Valley–A patient receiving oxygen through a tube suffered first- and second-degree burns (pdf) from a device using heat to removing skin tissue. $50,000
St. Mary Medical Center in Apple Valley–A patient with advanced cancer (pdf) was admitted to the hospital with abdominal pain but released after x-rays and other tests turned up negative. The patient said they felt somewhat better but was back in an hour with chest pain. Again, tests showed nothing and the patient went home. Twenty-three hours later, the patient returned, this time by ambulance. It turned out that x-rays on the initial visit had indicated an abnormal gas buildup that had not been conveyed to other doctors. The patient suffered a hole in their bowels, acute respiratory failure, septic shock, acute peritonitis, multiple abscesses and tissue death. $75,000
St. Bernardine Medical Center in San Bernardino–A 57-year-old male schizophrenic with a history of heart problems and high blood pressure was admitted for surgery on a cancerous neck lesion. The alcohol prep and use of oxygen with the laser tool, discouraged by instructions on some of the prep material, proved to be a bad combination. During outpatient surgery, a cauterizing tool ignited a flash fire (pdf) that burned the patient’s face, resulting in plastic surgery. $50,000
–Ken Broder
To Learn More:
Slideshow: CA Fines 8 Hospitals for Medical Errors (Health Leaders Media)
Fines Issued over Medical Mistakes (by David Downey, Riverside Press-Enterprise)
State Fines Eight California Hospitals for Safety Violations (by Jean Merl, Los Angeles Times)
Sharp Fined $100K for Fall (by Paul Sisson, U-T San Diego)
CDPH Issues Penalties to Eight Hospitals (California Department of Public Health)
Nine Hospitals Fined $775,000 for 10 Medical Horror Stories (by Ken Broder, AllGov California)