Multiple California Hospitals Cited For Errors

“Time Out!” This is becoming the “watchword” in the healthcare provider system these days to help prevent medical errors. If there is any doubt that a procedure is going to be correctly applied, any concern that a medication may not be the right one for the patient or any possibility that a “wrong site” might be operated on, medical staffers are being urged to take a “time out” and be certain.

The Department of Public Health in California recently cited 18 hospitals for medical errors. In many of these cases, had a “time out” been called or some extra care taken, none of these cases would have become a statistic and none of the hospitals would have been fined $25,000 per occurrence for the error. The penalties were issued under the authority of a recently adopted state Health and Safety Code signed by Gov. Arnold Schwarzenegger in January 2007.

While a number of the incidents might be considered rather minor, in 4 cases the errors contributed to patient deaths. In one case, a patient fell from an operating table and could have been seriously injured. In 2 others, surgical equipment remained inside the patient and required a second surgery to remove the items. The following are cases where serious errors occurred:

At Doctors Hospital in San Pablo, two separate incidents were cited due to patient death. In one, staff failed to follow correct procedures for handling critically low laboratory results and the patient died. In a second incident, the hospital failed to make certain that staff were competent in inserting intravenous catheters for a patient to receive proper fluids and nutrition.

The patient didn’t get adequate fluids and died

!

A patient death occurred at Grossmont Hospital in La Mesa when staff failed to activate a ventilator during the transfer of a patient from one ventilator to another.

At Los Alamitos Medical Center in Orange County one hospital staffer failed to ensure the safety of a patient by neglecting to apply a seatbelt in a wheelchair. The patient fell and died due to the fall.

At Fountain Valley Regional Hospital in Fountain Valley, a surgical sponge was left inside a woman’s body following a Caesarean delivery.

It was at Scripps Green Hospital in San Diego were a patient tumble off an operating table during surgery. Fortunately, the patient survive

Hoag Memorial Hospital Presbyterian in Newport Beach, was cited for a similar incident when a sponge was left inside a cancer patient. In both cases, a second surgery was required.

Some of the other incidents included hospital staff not ensuring the proper storage or dosage of medication, failure to have correct staff involved in a suicide watch and incorrect use of medical devices per manufacturer’s recommendations where possible death or injury could occur.

What is interesting to note in each case is that some patients might be alive today or others would not have required a second surgery had more care been taken to ensure patient safety or the correct delivery of a medical procedure. In each case, more attention to detail or a “time out” could have saved the patient or resulted in proper care.

Source: The State of California Department of Public Health. “California Department of Public Health Issues Administrative Penalties