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3 Bay Area Hospitals Fined for Medical Errors

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One patient had to be resuscitated after receiving the wrong medication

Three Bay Area hospitals are each facing $50,000 fines from the California Department of Public Health for medical errors that endangered patients, including leaving foreign objects in a patient’s body after surgery and administering the wrong medication.

Contra Costa Regional Medical Center in Martinez, Kaiser Foundation Hospital in San Francisco and Mills-Peninsula Medical Center in Burlingame are among the 12 California hospitals that the state assessed fines totaling $650,000 against on Thursday.

The hospitals have 10 days to appeal the penalties. Officials at Mills-Peninsula Medical Center said that hospital plans to appeal the fine, while Contra Costa and Kaiser Permanente will not.

At Contra Costa Medical Center on May 17, 2010, a nurse accidentally gave a mother, who had just delivered her second baby, the wrong medication intravenously.

The mix up took place, because the medication for epidural anesthesia had been delivered to the patient’s room during delivery and left by the patient’s beside, but not used. Post-partum, the mother was supposed to receive oxytocin, which is given after delivery to help clamp down the uterus and prevent bleeding. Instead, she received an intravenous jolt of a combination of bupivacaine and fentanyl.

The mistake caused the patient to suffer “seizures, cardiac arrest, requiring cardiopulmonary resuscitation, intubation, transfer to the Intensive Care Unit, and an increased length of hospital state,” the Department of Public Health found. (Read their documentation here.)

“There was no long-term harm to the patient and no harm to the baby, but of course we never want this to happen,” said Dr. William Walker, health director for Contra Costa County, which runs the hospital, adding: “The staff member was devastated by the event.”

To prevent the same mistake in the future, the hospital now allows only anesthesiologists, not nurses, to bring the epidural medication to patients' rooms. “We’ve taken it out of the nurses’ hands,” said Dr. Walker. “It can only go immediately to the anesthesiologist’s cart, which will prevent it from ever winding up beside again.” 

The hospital has also added additional labeling to the epidural bags.

But having heard that other hospitals have made the same mistake, Contra Costa has also lobbied the epidural manufacturer to change the connection on the bag so it can only be hooked up to an epidural catheter and never, mistakenly, to an I.V.

At Kaiser in San Francisco, the error occurred during the delivery of a baby. A mother, who had a Cesarian section on November 29, 2008, returned to Kaiser on January 1, 2010 suffering from pain and a temperature of 102. An X-ray showed a “foreign object” in the patient’s right lower pelvis. Surgery on that same day revealed that a fetal scalp electrode was causing infection, the Department of Public Health found. (Read their documentation here.)

“It is extremely unusual to have any incident with an unintended retained object after surgery,” said Christine Robisch, senior vice president and area manager, Kaiser Permanente San Francisco. “Nevertheless, these incidents should not occur, and we will not be satisfied until we have completely eliminated them.” The hospital does not plan to appeal the penalty and has done trainings of staff and physicians to try to prevent such future errors.

Mills-Peninsula Health Services plans to appeal the $50,000 penalty it received.

On December 14, 2009, a patient had surgery on his right eye, but on December 23, 2009 he came in to the outpatient clinic complaining of discomfort. Examination revealed “a small fragment of sponge was seen to have extruded from the conjunctive (thin membrane that covers the white surface of the eyeball) of the right eye,” the Department of Public Health found. (Read their documentation here.) In a second surgery on the same day, a fragment of cellulose sponge was removed from the patient’s eye.

In a statement, the hospital maintains that the “tiny microfiber retained in the eye of a patient during outpatient surgery” does not qualify as a “retained foreign object.”

The state hopes the fines will encourage the hospitals to be more vigilant. 

“We want California hospitals to be successful in their efforts to reduce hospital acquired infections, decrease medication errors and eliminate surgical errors,” said Pam Dickfoss, acting deputy director for the Center for Healthcare Quality at the California Department of Public Health, in announcing the fines. The department has collected $4.2 million in such penalties from the state’s hospitals since it began assessing fines in January 2007.

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