Yesterday the California Department of Public Health, CDPH, announced administrative penalties against 13 California hospitals, including the three Orange County facilities. For Hoag, it is the third such penalty in less than three years. Western previously received one other penalty in March 2009, and this was the first for St. Jude. All of these penalties are for serious patient care shortfalls and will cost each hospital $50,000.
CDPH reports “The administrative penalties are levied after a determination that the facilities’ noncompliance with licensing requirements has caused, or was likely to cause, serious injury or death to patients.”
Except for the University of California, San Diego Medical Center, Hoag was the only hospital on yesterday’s list which previously received two or more penalties. Of all Orange County hospitals, 12 have been assessed penalties since the program began in 2007. Hoag Memorial and Anaheim General Hospital are the only Orange County hospitals which have been penalized three or more times.
According to the state’s report, the penalty announced against Hoag yesterday was for a “deficiency constituting immediate jeopardy” to the patient which occurred on January 12, 2009. The patient, who “was known to have advanced breast cancer, with spread of the tumor to the brain and lungs”, received a “crush injury of the left lower extremity” when the Patient “was wheeled directly into the MRI room, and the metal wheelchair gurney was immediately forcibly attracted by the magnet against the outer core of the magnet housing, crushing the left lower extremity of Patient A and trapping the patient between the magnet and the metal wheelchair-gurney. This violation has caused or is likely to cause, serious injury or death to the patient(s).”
Based on our review of the report, it appears that this happened because the MRI technologist was busy on the phone making appointments instead of screening the current patient. According to the report, “the MRI technologist was on the telephone, scheduling MRI patients for the day, and was unaware, that Patient A was in the MRI unit.”
It was the technologist job to be sure the patients are “MRI safe.” The patient was wheeled into the MRI room without the benefit of screening by the MRI technologist and this is what caused the accident. This situation—where a technician is busy doing something other than following patient care procedures—sounds very similar to the situation which caused Hoag’s previous penalty. In this case, the patient died. See the related article below. We were not able to learn the medical outcome of the patient involved in the most recent penalty.
In Hoag’s previous penalty, stemming from a patient death on 12/31/2008, the state’s 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. In addition the governing body failed to provide adequate physical resources to ensure that the monitor technician was sufficiently free of other duties to ensure Patient A, who was off the cardiac monitor for greater than 30 minutes, was observed and treated.”
We asked Kathleen Billingsley, deputy director of the Center for Health Care Quality, CDHP, if these repeat violations at Hoag suggest a systemic problem and she said “If we {CDPH} identify any kind of systemic problem, the district offices immediately contact the hospitals and engage in further discussion if there are repeated incidences.”
The first penalty Hoag received was in August 2008 and was for “retained foreign object.” This means something was left inside a patient after a surgery and a second surgery was required to remove the object.
Removal of a foreign object after a surgery was also the reason for the recent penalty at Western Medical Center in Santa Ana. According to the report, “Patient #1 had undergone an emergency cesarean section and hysterectomy with removal of the left ovary and fallopian tube.”
The report continues “over the next several days, Patient #1 developed progressive leukocytosis, continued abdominal pain, and low grade fever. On 3/23/09 at 16:20 hours, an abdominal/pelvic CT scan was performed and the report stated a "foreign body appreciated within the lower pelvis." An operative report dated 3/24/09 documented Patient #1 had undergone an exploratory laparotomy under general anesthesia with removal of a retained laparotomy sponge. The violation(s) has caused or is likely to cause, serious injury or death to the patient(s).”
At St. Jude, the problem was failure to monitor a heart attack patient. The report states “the nurse failed to assess Patient G after a cardiac monitor change. Additionally, the clinical alarm system for the cardiac monitor was not set to ensure patient safety. Patient G died in the emergency room.”
The report’s findings include “Nurse A, while reporting off to the night shift nurse,
Nurse A, at the nurses' station, observed a "0" (no heart rhythm) on Patient G's cardiac monitor screen. The nurse stated she thought the patient's monitor leads must have come off. She stated she could see the patient sitting upright on the gurney and thought the patient was alright. She did not go over and check the patient.”
When asked what consumers could do to protect themselves from these avoidable medical errors, CDHP’s Billingsley said “By posting this information,, it’s available to the public, and they can go and ask their own hospitals –if I was going to have an elective surgery, I would be a very good advocate for myself in terms of looking at how many procedures of this type have been done at the hospital. I would also look at have their been adverse events, if there have, what has been done to correct them. I think it’s very important consumers become empowered to make sure that they look at the health care that’s being delivered.”
In other words, let the buyer be ware.
