Hospitals Fined for Endangering Patients

Accusations include leaving a surgical sponge inside a patient and 'causing a woman's bladder to explode.'


The California Department of Public Health Thursday announced administrative penalties totaling $375,000 against six Bay Area hospitals for non-compliance with licensing requirements that jeopardized the health and safety of patients.

The hospitals were among 14 in the state that were fined a total of $825,000. The hospitals can appeal the penalties.

Kaiser Foundation Hospital in South San Francisco was fined $75,000 for not following surgical policies and procedures that caused a patient to undergo a second surgery to remove a foreign object. San Jose Mercury News reports the "foreign object" was a surgical sponge left inside the patient. It was the
hospital's second administrative penalty.

Kaiser Foundation Hospital in San Francisco also was fined $100,000 for failing to ensure the health and safety of a patient by not following polices and procedures regarding self-administered bedside medications. It was the hospital's third administrative penalty.

Kaiser Foundation Hospital spokeswoman Melinda Skeath, executive director of Quality and Regulatory Services, said the medication administration policies at the San Francisco Medical Center were immediately revised and a detailed policy was developed regarding the use of self-administered insulin pumps in the hospital.

"We trained our staff on these procedures and monitor their adherence," Skeath said in a statement.

At the South San Francisco Medical Center, improvements were made in the processes to avoid retained foreign objects, and peri-operative staff was re-educated on certain policies, Skeath said.

"In addition, the medical center conducted a separate surgical safety course, focused on retained foreign object prevention strategies, attended by more than 70 surgeons, anesthesiologists, nurses and other clinical staff from the operating room," Skeath said.

Skeath said Kaiser hospitals continually invest in equipment designed to enhance patient safety, such as surgical equipment with fewer pieces and sponges that can be seen on surgical X-rays to reduce the possibility of retained foreign objects.

"Patient safety is our utmost priority at Kaiser Permanente," Skeath said.

Menlo Park Surgical Hospital in Menlo Park was fined $50,000 for not following established surgical policies and procedures. San Jose Mercury News reports it was a "botched exam" that caused a patient's bladder "to explode." It was the hospital's first administrative penalty.

Stanford Hospital in Stanford was fined $50,000 for failing to follow polices and procedures relating to tracheostomy care. It was the hospital's first penalty.

Saint Francis Memorial Hospital in San Francisco was fined $50,000 because a patient underwent a second surgery to remove a foreign object. It was the hospital's first penalty.

St. Mary's Medical Center in San Francisco received its first penalty for failing to ensure the health and safety of a patient during a transfer.

Dee Mostofi, director of marketing and communications for Saint Francis Memorial Hospital and St. Mary's Medical Center said "both hospitals take these matters very seriously."

"In each separate case, we conducted thorough investigations and are working closely with the medical staff, patient care team and hospital leadership, as well as with CDPH to ensure that an incident like this does not happen again," Mostofi said.

Mostofi said the hospitals will not discuss the specifics of the patients' care because of patient privacy laws.

Under legislation that took effect on Jan. 1, 2009, the penalties are $50,000, $75,000 and $100,000 for first, second and third or more offenses.

California Department of Public Health (CDPH) spokesman Ralph Montano said there is a proposal to increase each level of fines by $25,000 next year and public hearings will be held on the issue.

During a conference call with the media this morning, Debby Rogers, deputy director of the CDPH's Center for Health Care Quality, said 235 administrative penalties were issued against 135 California Hospitals between 2007 and 2011.

She said the most common administrative penalty - 27 percent - was for leaving a foreign object, usually a sponge, in a patient during surgery. She said the risk of that happening is higher in obese patients who have major surgery.

Before today, the California Department of Public Health has collected $6,637,000 in administrative penalties, Rogers said.

Issuing public notices of the penalties assessed against the hospitals allows patients to talk to their health care providers about the systems in place to prevent such errors, Rogers said.

- Bay City News Service


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