The California Department of Public Health usually relies on self-reporting by doctors and hospitals, which happens rarely, I have observed.
Adverse Events Draw $775K in Fines at 9 CA Hospitals
Cheryl Clark
HealthLeaders Media
October 28, 2013
The most recent round of administrative penalties for hospital deficiencies constituting immediate jeopardy includes two patient falls resulting in deaths, a wrong-site surgery, and a retained surgical object.
>>>Slideshow: CA hospitals penalized for medical errors
At Sharp Memorial Hospital in San Diego, a surgical team took out a man's healthy left kidney instead of his cancerous right one because the hospital didn't make imaging studies viewable in the operating room and because the surgeon "forgot" how to log-in to see them before cutting into the patient.
At Antelope Valley Hospital in Lancaster, a patient returned to the emergency department three times before doctors realized they had forgotten to remove a 9 x 6-inch surgical device. According to state officials, the device was not included in the instrument count.
And at Community Regional Medical Center in Fresno, a surgeon left the OR after instructing a physician's assistant to finish the surgery, which the assistant was not trained to complete. The patient suffered major blood loss, cardiac arrest, and loss of oxygen to the brain. At the completion of a state investigation, the patient remained on life support.
These major adverse events in California hospitals are among 10 detailed in state documents accompanying $775,000 in administrative penalties to these hospitals, which state officials announced last week. The fines are assessed once state investigators determine that lapses in regulatory compliance caused or likely caused serious injury or death to a patient.
Since these penalties began in 2007, the state had issued 295 penalties to more than 155 of the state's 400 acute care facilities, according to a statement issued Thursday by the California Department of Public Health.
Including the latest round of penalties, the state has assessed $13.3 million in fines and has collected $10.1 million. Most of the $3.2 million not yet collected is under appeal by the hospitals that dispute the state's findings.
The funds are to be used for programs to improve healthcare safety.
In a phone interview Thursday, Debby Rogers, deputy director for the state Department of Public Health's Center for Healthcare Quality, refused to comment on any particular hospital's harmful event, but acknowledged that some incidents are more serious than others.
New regulations due to take effect by the end of the year, will allow the state to consider how much patient harm was done "and how widespread inside the hospital a particularly deficiency is."
"We feel strongly that publicizing these deficiencies helps hold these facilities accountable but it also empowers consumers to speak to their providers to put protections in place so something like this doesn't happen," Rogers said.
...At Community Regional Medical Center, Fresno, Fresno County, a patient admitted for ascending aortic aneurysm repair suffered massive blood loss, cardiac arrest, and loss of oxygen to the brain after the heart surgeon left the operating room prior to the closure of the patient's chest during open heart surgery.
The surgeon instead directed a physician's assistant "to be left in charge, an individual not qualified to be left in charge of the cardiovascular surgery."
State investigators said the patient's loss of blood "required reopening the chest and manual massage of the heart." The patient was subsequently placed on life support.
Asked for an explanation, the surgeon said he had allowed the physician's assistant "to practice above her privilege card as 'she was preparing for an advanced quality practice exam and for that, she needed so many cases with opening and closing the chest and to cannulate the heart." The surgeon said he had always been there when she did this procedure "until this time."
State investigators wrote that the incident was reported through "an anonymous complaint," suggesting that the hospital may not have properly reported the incident as required by law.
The penalty is $75,000. This is the hospital's second administrative penalty...
10 California hospitals fined a total of $675,000
August 15, 2013
By Ari Bloomekatz
Los Angeles Times
Ten California hospitals, including Ronald Reagan UCLA Medical Center and Hollywood Presbyterian Medical Center, were slapped with fines Thursday totaling $675,000 because they failed to follow certain licensing requirements that "caused, or was likely to cause, serious injury or death to patients."
The fines ranged from $50,000 to $100,000, according to a news release from the California Department of Public Health.
St. Jude Medical Center in Fullerton, for example, was fined $100,000 for its fifth administrative penalty, according to the release.
"Based on observation, interview and record review, the hospital failed to follow their policy and procedure to have relevant images and results properly labeled and displayed prior to a patient's surgery," according to documents provided by the public health department. "This failure resulted in the removal of the wrong kidney."
The penalty against UCLA's hospital was for not following the proper surgical policies and procedures that led to "a patient having to undergo a second surgery to remove a retained foreign object." The hospital was fined $50,000...
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