Two hospitals in San Diego were today fined $25,000 each by the California Department of Public Health for incidents that caused, or could have caused, serious injury or death to patients.
UC San Diego Medical Center-Hillcrest was fined because it "failed to ensure the health and safety of a patient when the hospital did not follow its surgical policies and procedures," according to the DPH.
The incident resulted in a patient having to undergo a second surgery to remove a foreign object.
According to a DPH report, a surgical sponge was left in a patient who underwent spinal surgery.
In a statement, UCSD Medical Center officials said they "deeply regret the error," which was immediately reported to the DPH and a plan of corrective action implemented.
"During the procedure, a tiny sponge was inserted in the incision in order to keep the area dry," the statement says. "An X-ray taken during a routine three-month follow-up appointment revealed the sponge, which was successfully removed with no adverse complications to the patient."
Scripps Mercy Hospital was fined by the DPH because it "failed to follow its policies and procedures for the use and maintenance of respiratory equipment," according to the state agency.
According to Dr. Davis Cracroft, senior director of medical affairs at Scripps Mercy, a ventilator being used to treat a patient with a traumatic brain injury malfunctioned.
The ventilator malfunction was "recognized, but by the time it was recognized, the patient had gone for some time, several seconds, without appropriate ventilation," Cracroft said.
The patient survived, but was left in a "vegetative state," he said.
It wasn't determined whether the ventilator malfunction or the brain injury led to his condition, according to Cracroft.
The hospital made a report to the DPH and immediately implemented "corrective actions" including, removing any faulty equipment, putting in place new safeguards and educating caregivers, Cracroft said.
"It was a lesson we learned in a very sad manner," he said.
Both hospitals had been fined by the DPH once before.
The latest fines pertained to incidents that occurred in 2008, according to the DPH, which began issuing administrative penalties against hospitals in 2007 following a change in the state's health and safety code.
The fines for incidents that occur in 2009 will double to $50,000, according to the DPH.
Most of the incidents are self-reported by the hospitals, which are required to implement a plan of correction to prevent similar occurrences in the future.
The hospitals can appeal the penalties.
Cracroft was critical of the DPH's policy of hitting hospitals with fines, arguing that the penalties were "not wise" and the focus should instead be on learning from mistakes and making sure they don't happen again.
He said the fines may make some hospitals less inclined to report mistakes.
"In some instances, placing a monetary penalty may make one think twice about reporting," Cracroft said.
"We are still humans working in an environment where errors do occur," Cracroft said, adding that he fully supports open reporting of incidents impacting patient care and "appropriate" investigations.
