Latest California hospital “never events” include four deaths and an operating room fire
Friday, December 21, 2012
The announcement of yet another round of fines against California hospitals for “never events” that left a dozen patients injured or dead emphasizes the need for state lawmakers to adopt tougher restrictions holding the health care industry more fully accountable for negligent acts.
The latest incidents penalized by the California Department of Public Health — all stemming from events that state health officials agree should never happen in a hospital — included four deaths, an operating room fire that led to second-degree burns of a patient, and two cases in which a surgeon performed the wrong surgical procedure. In one of those cases a surgeon removed the healthy kidney from an 85-year-old man who had a suspected cancerous mass on the other kidney. There were also five cases in which patients had to undergo additional surgeries to remove items that had been left in their bodies after the first operation.
Just in the last six months CDPH has issued 39 penalties for hospital “never events.” Since the agency began issuing these penalties in 2007 it has fined 141 of the state’s acute-care hospitals for 254 events. Two of the hospitals cited this week (Mission Hospital Regional Medical Center in Mission Viejo and UCSF Medical Center in San Francisco) have now been penalized six times.
One of the patients who died inexcusably was a 29-year-old woman who was undergoing an outpatient procedure to remove a birthmark from her upper lip at Kaiser Foundation Hospital in Oakland. She died of an embolism caused when a surgical laser introduced gas bubbles into her bloodstream. The physician involved had not been trained in the use of the laser and had not read the instruction manual for the device.
In another case, at Kaiser’s South Bay Medical Center in Harbor City, a woman undergoing surgery to repair bleeding in her digestive tract bled to death when she was given an anticoagulant instead of the medication to promote blood clotting the surgeon had called for.
The latest penalties come on the heels of two other disturbing reports about patient safety. A study by researchers at the Johns Hopkins University School of Medicine found totally preventable surgical “never events” occur at least 4,000 times a year in the United States. And the physician president of The Joint Commission, a non-profit that accredits health care organizations in the U.S., said hospital care in this country is 3,000 times less safe than air travel.
These numbers are coming from doctors, not lawyers. The medical profession understands there’s a serious problem. Yet California’s unjust MICRA law continues to limit compensation for those harmed, not only through no fault of their own, but by medical catastrophes that should never, ever happen. These egregious medical errors need to stop, but when they do happen, those responsible need to be held fully accountable to those who are harmed.
–J.G. Preston and Eric Bailey