California Department of Health Fines 12 Hospitals for Patient Safety Violations

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Twelve California hospitals have been penalized with varying fines for failing to meet licensing requirements that caused or was likely to cause serious injury or death to patients, according to a department news release.

AHMC Anaheim (Calif.) Regional Medical Center was issued a $50,000 fine after it was discovered the hospital performed a wrong-site surgery on a patient. According to department records, the patient was diagnosed with a right-side kidney stone but improperly received a left-side stent.

Contra Costa Regional Medical Center in Martinez was also issued a $50,000 fine. According to department records, the hospital incorrectly administered fentanyl and bupivicaine intravenously to a patient instead of Pilocin. As a result of the medication error, the patient experienced seizures and cardiac arrest, leading to a longer hospital stay.

Dominican Hospital in Santa Cruz was issued a $50,000 fine for failure to adhere to its patient care policies and procedures for on-going patient monitoring. A patient with chronic obstructive pulmonary disease exacerbation was started on respiratory ventilation with 30 percent oxygen. Per the hospital's policy, patients on a BiPAP unit must be assessed 30 minutes before and 30 minutes after initiation of BiPAP. Hospital personnel failed to monitor the patient after initiation, leading to his death. This is the second administrative penalty issued to the hospital.

Emanuel Medical Center in Turlock must pay a $50,000 penalty after the department discovered a physician failed to follow hospital procedure in administering droperidol.  According to official records, five patients improperly received the medication. A boxed warning issued by the FDA states improper administration could lead to death and also outlines caution specifications, which the provider failed to follow.

Kaiser Foundation Hospital in San Francisco was issued a $50,000 penalty. According to documentation, a physician and nurse failed to follow hospital protocol in counting instruments to ensure all instruments have been accounted for following a procedure. Their failure resulted in a follow-up surgery to remove a fetal scalp electrode from a patient, who complained of pain and fever three weeks after her original procedure.

Mills-Peninsula Medical Center in Burlingame must also pay a $50,000 fine for failure to follow hospital protocol in counting surgical sponges, designed to prevent retained surgical items in patients. According to the department, a cellulose sponge was left in a patient's eye during surgery, forcing the patient to undergo a second procedure to remove the instrument.  

Palomar Medical Center in Escondido was ordered to pay a $75,000 administrative penalty after a nurse failed to follow hospital procedure regarding the administration of analgesics. The nurse improperly administered 33 times the amount of analgesics to a patient, which led to the patient's death. This is the second administrative penalty issued to the hospital.

Pomerado Hospital in Poway must pay a $75,000 penalty for failure to follow policies regarding care for patients at high risk of falls. Department records show a patient with documented history of confusion and agitated behavior was admitted to the hospital. Despite repeated incidences of getting out of bed unassisted, the hospital failed to implement safety alternatives to prevent his fall, which caused several skull fractures and his eventual death. This is the third administrative penalty issued to the hospital.

Promise Hospital of East Los Angeles has been ordered to pay a $50,000 administrative penalty for incorrect medication administration to a patient. According to the department, a physician order called for a medication switch from daily Cardizem CD 180 mg to Cardizem 60 mg via gastrostomy tube. However, the patient was improperly administered four doses of 600 mg Cardizem, leading to severe bradycardia among other complications.  

Scripps Memorial Hospital – Encinitas was issued a $50,000 penalty for failing to account for all surgical instruments used during a patient's procedure. According to the report, an OR team failed to account for a malleable retractor, which was left inside a patient. The retained surgical instrument required a second surgery for removal.

Scripps Memorial Hospital – La Jolla must pay a $75,000 administrative penalty for failure to follow protocol in accounting for all surgical instruments during a procedure. According to documentation, a technician improperly left a 28-inch guide wire inside a patient while undergoing cardiac catheterization. The object was later found in the patient's right femoral artery 29 days later during a second cardiac catheterization procedure. This is the second administrative penalty issued to the hospital. 

Sharp Memorial Hospital in San Diego was ordered to pay $25,000 after a patient died as a result of improper medication administration, stemming from lack of nursing competency. According to the department's report, a registered nurse failed to demonstrate competency in using a specific infusion pump but was responsible for using one anyway. As a result, a patient was administered 3.6 times the amount of medication originally prescribed and later died.

Read the California Department of Public Health's news release about its administrative penalties to 12 California hospitals.

Related Articles on Hospital Quality:
Patient Safety Tool: AHRQ Pamphlet for Reducing Medication Errors
Connecticut Surgery Center Fined, Placed on Probation for Safety Violations
AHRQ: 20 Tips to Help Prevent Medical Errors in Children

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