Immediate Jeopardy: Words No Hospital Official Wants to Hear

Cheryl Clark, for HealthLeaders Media , June 3, 2009

Similar financial penalties are contemplated for nursing homes in the event a patient is harmed, or in immediate jeopardy of being harmed.

In California, there is an imperative to use the mistakes as an opportunity to learn how to avoid them.

Of the $2.175 million in fines assessed, the state has collected $1.2 million as of Jan. 1 of this year. All of the funds are legally required to be spent for quality improvement research and monitoring, state officials say.

Licensing and certification officials expect the first $300,000 of the money to be released in the next few months, and plans to spend $150,000 of it to hire a consultant who would review and track more than 1,000 adverse events in general acute and psychiatric hospitals that were reported to the state. All but the 87 were not serious enough to merit a finding of immediate jeopardy.

The other $150,000 will be used to bring "a culture change" to chronically challenged nursing homes—facilities that represent a significant share of state investigators' workload.

Already, efforts are underway to alleviate the biggest reasons for adverse events. In the fiscal year ending June 2008, the state investigated 581 instances of stage 3 or 4 pressure ulcers acquired after a patient's admission. There were a reported 165 instances of a foreign object such as a sponge or device unintentionally retained in a patient. And, 33 patients died due to an avoidable fall.

It's unclear whether health reform programs now being proposed at a federal level will result in fines. Although it is now established that the federal government will no longer pay for any follow-up care required as a result of a "never" event, such as surgery on the wrong patient, surgery on the wrong body part, or the wrong procedure.

If there are to be fines, however, perhaps the money can likewise be put to good use at a national level to promote research into the circumstances that lead to such events, as well as solutions for how they can be avoided.

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Cheryl Clark is senior quality editor and California correspondent for HealthLeaders Media. She is a member of the Association of Health Care Journalists.

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