It's so horrible that it almost sounds like a joke. You go into a hospital for surgery, and as the doctors close you up their leave their tools inside you, requiring still more surgery to get their stuff back out. But, as we know, it happens — and two local hospitals are facing hefty fines for exactly those types of screw-ups.
The California Department of Health announced Wednesday that they are issuing fines to 12 California hospitals "after investigations found the facilities’ noncompliance with licensing requirements caused, or was likely to cause, serious injury or death to patients." Included in that list: California Pacific's Pacific Campus Hospital in San Francisco and Marin General Hospital in Greenbrae.
On 5/30/13 Patient A had a Robotic-assisted total hysterectomy (surgery for removal of the uterus). A Jackson Pratt drain bulb (A soft round squeeze bulb) was placed in Patient A's vagina in the OR (Operating Room).
The Jackson Pratt drain bulb was not accounted for during the final surgical count (a method whereby the surgical staff accounts for all instruments, sponges, needles and specific small items to prevent retention and injury to the patient).
The retention of this Jackson Pratt drain bulb required Patient A to go to the Emergency
Department complaining of abdominal pain and fever. The retained Jackson Pratt Bulb was removed. The patient was given antibiotics then was transferred to the hospital where Patient A had to be admitted for a period of three days for an infection due to retention of the Jackson Pratt drain bulb.
The patient's emergency room admitting report reads that she:
...presents to the emergency department with abdominal pain of the left lower quadrant described as constant sharp...symptoms/episode began occurred since surgery on 5/30/13...fever today...Pelvic Exam...Speculum Exam: positive FB (Foreign Body) in vagina, removed, found to be bulb from Jackson Pratt drain. Foul smelling...lmpression: fever, Infected vaginal foreign body, rule out Intra-abdominal infection.
Allow me to be the first to say ugggggh oh my god. For their crimes, described by the CA DPH as a failure "to ensure the health and safety of a patient when it did not follow surgical policies and procedures," Cal Pacific was fined $75,000. This is their fifth "Immediate Jeopardy" administrative penalty, CA DPH says. You can read the full report on that mess here.
Meanwhile, over at Marin General, a patient who had cranial surgery went home with an unexpected parting gift:
Patient 1 was admitted on 08/12/13 and discharged on 08/19/13. On 08/12/13, Patient 1 had cranial surgery and on 08/14/13, Patient 1 had a second surgery to remove a disposable surgical scalp clip from the first surgery...the surgeon brought Patient 1 back to surgery and placed a "burr" hole (a hole that is drilled into the skull ) and removed the surgical clip through the hole.
The clip, a "green plastic object measuring 1.5 x 1 x 1 cm, was a disposable surgical scalp clip. Marin General's Operating Room Director told an interviewer "that it was not their practice to count disposable surgical scalp clips in the past."
According to the CA DPH, this lack of practice is "a violation of section 70223(b)(2) of Title 22 of the California Code of Regulations," for which Marin General was fined $100,000. This is their fifth Immediate Jeopardy administrative penalty. The full report on that case is here.
If you want to check out the other 10 hospitals on the penalty list, you can do so here. Clicking on the hospital name in each entry will get you the detailed report of the incident, and clicking on the county name in each entry will get you a long list of recent Hospital Administrative Penalties for each locale. And there goes your afternoon!