The California Department of Public Health (CDPH) handed out “administrative” penalties totaling $785,500 to 10 hospitals this week for 12 unfortunate incidents, some of which had deadly consequences. The mistakes that led to the fines included wrong-site surgery, screwed up medication and misplacement of surgical materials inside patients.
Four of the incidents were in Kaiser Foundation Hospitals. The facility in Oakland was fined $100,000 because “Physician A” didn’t know how to properly operate a laser used during an operation and, “as a consequence, Patient 1 suffered a fatal vascular embolism.”
It only cost Kaiser in San Diego $75,000 after “Patient L” had his right kidney successfully removed. Unfortunately, that was his good kidney. The left kidney had been identified over a four-year period as having a suspected cancerous tumor mass. The public health department report noted that the patient’s wife did not know which organ was to be removed “and trusted that Surgeon S was aware of the affected kidney.”
Failure to remove some “gauze packaging” from a patient before closing him up caused an infection and cost Kaiser of San Rafael $50,000. Kaiser in South Bay also was fined $50,000 for giving a blood thinner to a patient, instead of a coagulant, during gastrointestinal surgery. “The patient was treated with multiple units of blood products and medications but expired.”
Pregnant “Patient 1” at Kaweah Delta Medical Center in Visalia was admitted for a normal vaginal birth, but bled to death after her uterus was punctured by a “sterile pointed instrument.” The patient had begun bleeding in the delivery room, and continued to bleed after being moved to the operating room, where the attending physician declined an opportunity to call a Rapid Response Team. The fine was $50,000.
“Patient 1” at Methodist Hospital of Southern California in Arcadia was originally admitted with gallbladder problems. The patient was operated on, then returned five more times to the hospital with chest pain, headache and an inability to urinate. Upon review, surgeons found a surgical sponge stuck to the patient’s stomach wall, necessitating a piece-by-piece removal. The penalty was $50,000.
Sutter Coast Hospital in Crescent City was fined $10,000 after a patient who was admitted for removal of a basal cell carcinoma (skin cancer) suffered second-degree burns on her face from a flash fire ignited by use of an electric cauterizing device next to her oxygen mask. The mask caught fire, as did the surgical drapes around the patient’s head.
The state used to fine hospitals $25,000 for mistakes of this sort, but a new law upped the ante in 2009 to fines that top out at $100,000 for a third offense.
–Ken Broder
To Learn More:
10 California Hospitals Fined for Medical Errors (by Anna Gorman, Los Angeles Times)
CDPH Issues 12 Penalties to California Hospitals (California Department of Public Health)