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Four Bay Area hospitals are facing fines of $50,000 each from the California Department of Public Health for errors that, in some cases, put patients' lives in danger.

Alameda Hospital in Alameda, Kaiser Foundation Hospital & Rehabilitation Center in Vallejo, Sutter Delta Medical Center in Antioch and UCSF Medical Center in San Francisco were among 12 hospitals against which the state assessed fines totaling $650,000 on Wednesday.

At the Kaiser hospital in Vallejo, a patient had to undergo two cataract surgeries in 2009 because a surgeon implanted the wrong lens, according to documents posted on the state health department's website. The first lens was designed for the patient's wife, who had surgery scheduled with the same surgeon a month later.

“It is extremely unusual to have any incident in which the wrong procedure is performed,” said Max Villalobos, senior vice president and area manager for Kaiser Permanente in the Napa-Solano area. Since the incident, the hospital has modified its preoperative procedures and retrained staff to prevent such mix-ups from occurring again, he said.

At Sutter Delta Medical Center in Antioch, an emergency room physician ordered staff to use a cardiac monitor to care for a patient suffering from atrial fibrillation, an abnormal rhythm of the upper chambers of the heart, among other maladies. The staff failed to do so for more than 40 minutes, an investigation found.

When the patient went into cardiac arrest, the lack of monitoring resulted in a delay in cardiopulmonary resuscitation. The patient suffered irreversible brain damage due to lack of oxygen. He died two days later, after being removed from life support.

The medical center has subsequently improved “training, documentation, processes, communication and accountability to prevent an event like this from recurring,” said Angela Juarez-Lombardi, a spokeswoman for Sutter Delta Medical Center.

At UCSF Medical Center, a sponge was left inside a patient during surgery in 2010, after a nurse failed to follow the hospital’s policies for keeping track of surgical objects. 

The hospital responded immediately by having faculty and staff review safety procedures, according to Ken Jones, the medical center's chief operating officer. The hospital has instructed surgical staff to keep track of all sponges by scanning the bar codes that are affixed to them, Jones said.

At Alameda Hospital in 2009 and 2010, medical staff made no attempt to establish seven patients' tolerance to opiates before prescribing fentanyl, a powerful narcotic pain reliever. Two of the patients died while receiving the medication, the state's investigation found.

"This failure exposed 7 of 7 patients reviewed, who had not been on fentanyl patches prior to admission to the hospital, to preventable adverse consequences including respiratory depression (severe trouble breathing) and death," the investigation found.

Since the incidents, the hospital has reorganized its pharmacy department and implemented new policies to avoid such medication errors, according to a statement emailed to The Bay Citizen. “Clinical staff received extensive education regarding Fentanyl Transdermal Patch use in patients,” the statement read.

The fines announced Wednesday were for incidents that took place in 2009 and 2010. After a significant medical error occurs, the health department investigates and documents its findings. The hospital then files a plan of correction, and the health department conducts an unscheduled inspection. "Only after all that has taken place — only then do we consider the possibility of being assessed a fine," said Ralph Montano, a spokesman for the California Department of Public Health.

Legislation that took effect in 2007 allows the state to assess penalties against hospitals. Prior to that, the state's only enforcement tool was to take a hospital's license away if the hospital failed to correct problems. 

Since 2007, the California Department of Public Health has assessed a total of 198 administrative penalties against 124 California hospitals. It has collected $4.6 million, which the department says is to be used to improve the quality of health care in the state.

Dangerous medical errors have declined by 12 percent in the state’s hospitals since the law took effect, according to Pam Dickfoss, acting deputy director of the state’s Center for Healthcare Quality.

“It is our expectation that these events in hospitals will decrease over time,” she said.