Yesterday morning the California Department of Public Health (CDPH) announced that 3 Orange County hospitals, along with 9 other California hospitals, have been assessed administrative penalties of $25,000 per violation. The penalties were assessed after a determination that the facilities’ noncompliance with requirements of licensure caused, or was likely to cause, serious injury or death to patients. Two of the OC events involved inadequate patient monitoring, one of which, at Hoag Memorial, resulted in the avoidable death of the patient. The other monitoring failure, at Children's Hospital, resulted in brain injury to a baby girl, and the third OC event required an avoidable second surgery.

The 3 OC hospitals are Children’s Hospital of Orange County, Orange, Hoag Memorial Hospital Presbyterian, Newport Beach, and South Coast Medical Center (Mission Hospital Laguna Beach), Laguna Beach. While Los Alamitos Medical Center received a similar fine for the avoidable death of a patient in 2007, none of the West OC hospitals were on the current list.

The violation which occurred at Mission was for "retained foreign objects", otherwise known as something was left inside a patient after a surgery and another surgery was required to remove it. Since these citations are limited to the specific procedural failures, the reports often do not comment on the consequences for the patients.

The violation which occurred at CHOC involved the inadequate monitoring of a baby girl. This avoidable failure to follow procedures left the child with brain injury and in an "unresponsive" state.

According to Ralph Montano of CDPH, these administrative penalties are for serious preventable problems only, and apply to two different categories. Those categories are called "adverse events" and "immediate jeopardy" problems. The law that took effect January 1, 2007 identifies 28 specific adverse events. Effective July 1, 2007, The hospitals are required to report when any of the 28 events happen, but not every adverse event will result in a fine. For example, the list of 28 adverse events includes a death within 24 hours of surgery, but if the death was not the result of the hospital doing something wrong, they would not be fined.

If a patient dies or is seriously injured because of something preventable which the hospital did wrong, there will be a fine and a public disclosure. Although there are a few different ways by which the CDPH becomes aware of these events, the system is certainly not failsafe. You can check this out for yourself.

First, click here to go to the list of frequently asked questions. Scroll down and you will find the list of 28 adverse events. If one of these looks familiar, then click here to go to the list of hospital penalties. Just select the county of interest and you will have a list of all the penalties in that county. Montano said "Before these laws existed, they {the hospitals} weren't required to report these things and they didn't." He said "absolutely" people should file a complaint if they know one of the 28 adverse events occurred after July 1, 2007, but do not see it on the penalty list.

Your Editors asked each of the three OC hospitals for a statement regarding the fines. following is the statement from CHOC. The incident at CHOC involved the avoidable deficient monitoring of a baby girl.

"CHOC Children’s is committed to providing the highest level of quality care, safety and support to our patients and their families. As part of this commitment, the hospital has a strict policy of reporting and investigating any incidents of care that may have not fully met our quality standards, and we followed this procedure with the incident that occurred with one of our patients in November 2008. We very much regret this incident and the impact it has on our patient and the patient’s family. We are privileged to continue to be involved in the care of this patient and are working with the family to ensure the child’s medical needs are being met.

In addition to reporting this incident to the California Department of Public Health, we immediately conducted our own internal investigation. As a result of our own investigation, we have adjusted various protocols for patient care, increased staff training and set up additional layers of checks and balances to minimize the chance that this type of incident could occur in the future. Our highest priority remains the safety and quality of care provided to all of our patients."

Dr. Maria Minon, Chief Medical Officer, CHOC Children’s

The incident at Hoag involved the avoidable death of a patient and it was Hoag's second penalty. The report indicates the hospital "failed to ensure that the attending physician's order for continuous cardiac monitoring was implemented as ordered, resulting in Patient A being at risk for undetected cardiac arrhythmias. Subsequently, Patient A was found to have suffered ventricular fibrillation, coded and expired."

Here is the statement we received from Hoag:

"Hoag recently reported an incident to the California Department of Public Health where our established patient safety procedures for monitoring a patient’s heart rhythm were not followed. Unfortunately, this incident involved a patient death.

An extensive investigation of the incident was conducted.  To prevent a future occurrence, we added additional staffing on the unit so that one person is able to constantly observe the heart monitors without distractions and immediately inform the nurse of rhythm changes. In addition, staff has been re-educated on their roles and responsibilities related to heart monitoring and communication of rhythm changes.

Richard Afable, M.D.
Hoag Hospital President and CEO

The release from the CDPH reported for Hoag "The hospital failed to ensure the health and safety of a patient when the hospital staff did not follow physician’s orders for continuous patient monitoring. This is the second administrative penalty issued to this hospital. A previous penalty was issued in 2008 for failure to follow surgical policy and procedure resulting in a second surgery to remove a retained foreign object."

South Coast Medical Center (Mission Hospital Laguna Beach) was owned by Adventist Healthcare when the incident occurred. It is currently owned by Mission Hospital of Mission Viejo, which is in turn part of St. Joseph Healthcare System. The current owners declined to provide a statement regarding the incident related to the penalty. Your Editors did not contact the previous owners.