3 local hospitals are fined for errors

UCSD facility punished for third time since 2007

By Mike Lee, UNION-TRIBUNE STAFF WRITER

Thursday, January 28, 2010 at 1:34 a.m.

LOCAL HOSPITALS FINED

The California Department of Public Health yesterday announced penalties against 13 hospitals, including three in the county for violations dating back to January 2009:

• Sharp Grossmont in La Mesa, for performing surgery on the wrong side of a patient’s brain.

• Sharp Memorial in San Diego, for leaving a surgical sponge in a patient.

• UCSD Medical Center in San Diego, for leaving a guide wire in a patient’s catheter line.

State health regulators have slapped the most severe fines on 13 medical centers, including three local facilities, for preventable mistakes that put patients in severe jeopardy. This latest batch of penalties raises broader concerns about the ability of hospitals nationwide to stem a decades-long string of errors.

Two of the local cases announced yesterday by the California Department of Public Health involved surgical items left in patients. In the third incident, surgeons operated on the wrong side of a 93-year-old man’s brain.

The lapses in care embarrassed hospital administrators from San Diego to Sacramento, who said they have set up redundant safety protocols in hopes of avoiding future mistakes.

For UCSD Medical Center, the fine was its third since the state’s hospital penalty program started in 2007. Sharp Memorial Hospital in San Diego was issued its first fine, and Sharp Grossmont Hospital in La Mesa got its second.

The three institutions were ordered to pay $50,000 each for their violations, which all took place in January 2009.

California’s latest round of penalties largely kept pace with the number of fines it has issued about every six months. Over the past three years, hospitals have been assessed 134 such fines. Leading problems include medication errors and “foreign objects” that remain inside patients after surgery, the same preventable accidents that have bedeviled hospitals nationwide for years despite growing attention from Medicare, health analysts and others.

During a teleconference yesterday, state health regulators were peppered with questions about the continuing pattern of mistakes.

“We have asked hospitals those same questions: How can this happen?” said Ken August, a state public health agency spokesman.

The answers typically boil down to systematic deficiencies — such as failure to recognize drug allergies and not properly checking devices — that sometimes result from medical professionals who fail to follow industry-proven best practices.

“People have to remember that although 21st-century health care is very technologically advanced, it is still delivered by humans, and humans are still subject to making mistakes,” said Jan Emerson, a spokeswoman for the California Hospital Association.

Emerson urged the public to keep the problems in perspective, stressing that there are more than 3 million hospital discharges each year in California.

“When these incidents happen, hospitals go back and they dig deep to look at the core reasons these things happened and they fix that,” she said.

Administrators at various medical centers said they have launched initiatives to combat carelessness, lack of training and other basic shortfalls. Sharp Health Care, for instance, has experimented with using sponges that have radio tags so they can be located with a hand-held scanner before surgeries are finished.

Last week, the Hospital Association of Southern California and other industry groups announced a three-year, $6 million campaign to improve patient safety.

In addition, California’s public health officials are proposing to divert $800,000 in fines paid by hospitals to an initiative to minimize the number of surgical devices left in patients.

Not everyone is confident that health officials are seeing the full range of problems because the state’s system relies on hospitals to report their mistakes.

“It’s really hard to tell from the data that is out there now what the real number is,” said Betsy Imholz, special projects director for Consumers Union, the nonprofit publisher of Consumer Reports magazine.

Imholz wants California to be more aggressive in counting and publicizing major gaps in care at hospitals.

“Studies have shown that putting safety and quality information out in the public realm spurs hospitals to engage in self-improvement,” Imholz said.

Nationally, tracking systems for medical errors are so poor that it’s difficult to tell whether the situation is getting better or worse, said Dr. Brent James, the chief quality officer at Intermountain Healthcare in Salt Lake City and a national authority on the topic.

“The vast majority of patient injuries are never detected,” James said.

He said the key to reducing errors is having protocols in place that can help avert common problems, such as drug overdoses. Some mistakes, including misplaced surgical devices, probably will continue to haunt hospitals.

“The ability to reduce that number to zero probably just isn’t realistic,” James said, adding that people shouldn’t lose faith in the system. “The benefits from care far outweigh the harm.”

UCSD Medical Center’s fine was spurred by an intern who left a guide wire in a catheter line. The staff had to perform a second surgery to remove it.

The hospital’s officials refused to be interviewed about the case. In a statement, they expressed regret for the error and said they had worked with state regulators to develop a correction plan.

At Sharp Memorial, a similar problem occurred during a heart operation on a 69-year-old woman. Her blood pressure failed to stabilize after surgery, state records show. That prompted an X-ray that showed a sponge had been left inside her, and a second surgery was needed to remove it.

California fined Sharp Grossmont for starting surgery on the wrong side of a patient’s brain.

“The entire surgical team failed to recognize that the right side of (the patient’s) head had been incorrectly marked by (a surgeon),” state investigators said in a report.

“Clearly, a process that was well thought-out … was not executed properly,” said Nancy Pratt, chief quality officer for Sharp Health Care. “It was a tragic circumstance.”

Pratt said no one was fired for the two incidents in her hospital network, where administrators have focused on preventive steps such as emphasizing that surgery markings must be made before patients enter the operating room. The earlier action allows for more checks.

“It’s never a single failure point that ends up in one of these events,” Pratt said.