13 Hospitals Fined for Mishaps, Never Events

Cheryl Clark, for HealthLeaders Media , May 20, 2009

California has imposed its sixth round of fines against hospitals for serious mishaps and so-called never events, such as fatal errors with high-risk medications, surgery on the wrong patient and three cases in which objects were left inside patients during surgery.

One hospital was fined for not promptly investigating an alleged sexual assault by a staff member against a patient.
Other reasons for the punitive actions by the California Department of Public Health, which licenses about 450 acute care facilities throughout the state, were failure to properly transfuse a patient and the incorrect use of respiratory equipment.

Administrative penalties of $25,000 were assessed on the facilities for events occurring in 2008.  Incidents that occur after Jan. 1, 2009 will be fined $50,000.

These penalties will bring $350,000 to the state to implement better safety strategies in acute healthcare settings. Since the law allowing hospitals to be assessed a monetary fine took effect in 2007, 87 fines have been levied against 59 hospitals, for a total of $2.175 million, said department director, Kathleen Billingsley.

About $1.2 million has so far been collected. However, 18 of the hospitals are still appealing their fines.

Billingsley said that far from just "showcasing" hospitals that made serious errors, the public announcements of these penalties prompts all hospitals to improve. "The hospitals go back and say 'Wait a minute. Do we have a process to prevent this from happening here?'" she said.

As a result of knowing how things go wrong, "the best practices are being developed and have been developed."  Much of the time, she added, "it's a process breakdown" which prompts the hospitals "to put in additional checks and balances to make sure something like it doesn't happen again."

The state is using the fines to fund safety and error prevention programs. Billingsley's department is in the process of analyzing the errors and their underlying causes, and will at some point issue a report.

The hospitals assessed fines in this announcement include Brotman Medical Center, Hollywood Presbyterian Medical Center, Harbor-UCLA Medical Center, Saint Francis Medical Center, and Whittier Hospital Medical Center in Los Angeles County; St. Jude Medical Center, University of California Irvine Medical Center in Orange County, which received two fines; and University of California San Diego Medical Center and Scripps Mercy Hospital in San Diego County.

Fines were also levied on Clovis Community Medical Center and St. Agnes Medical Center in Fresno County, John Muir Medical Center in Contra Costa County, and the University of California San Francisco Medical Center in San Francisco County.

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