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CDPH Penalizes Seven Hospitals $775K

New Report Discloses Adverse Patient Events Are Rising

By Ron Shinkman

Feb 7, 2013

California Region

The California Department of Public Health on Wednesday levied 10 penalties against seven hospitals for medical errors that killed or gravely endangered patients in 2011. A department official also disclosed that the rate of adverse events in California's hospitals has yet to stabilize – the first step in their moving toward a consistent downward trend.

The penalties were accompanied by $775,000 in fines, which ranged from $50,000 to $100,000 per penalty. Since the CDPH was empowered in 2007 to fine hospitals for life-threatening mishaps, it has levied fines totaling $10.4 million, and has collected $8.2 million. As of last month, 28 hospitals were appealing their penalties – a process that can delay the payment of a fine by years, officials said.

Despite announcing 22 administrative penalties against hospitals in the last seven weeks, data compiled by the CDPH over the last year indicates medical mishaps at the state's hospitals continue to rise.

According to a report released by the agency last week, a total of 1,558 adverse events occurred in California's hospitals during the 2012 fiscal year that ended last June 30. That compares to 1,515 in fiscal 2011 and 1,468 in fiscal 2010. Adverse events are recorded in 28 different categories, include retained surgical objects, deaths or injuries from medication errors, falls, and burns, among others.

Debby Rogers, the deputy director of CDPH's Center for Health Care Quality, said that the agency plans to publish specific data on individual adverse events starting in January 2015.

Currently, few adverse events lead to administrative penalties. CDPH officials use eight separate criteria to determine whether such events merit a penalty and fine, according to agency spokesperson Ralph Montano. He added that the evaluation process was too complex to clearly delineate.

“We don't have enough data yet to see a decline in adverse events,” Rogers, said at a media conference to discuss the penalties meted out on Wednesday. “It's becoming more consistent...but we don't yet have enough data to see a decline.”

The admission by Rogers represented somewhat of an about-face – she had suggested in the past that the reporting of the administrative penalties and fines was putting pressure on hospitals to be more vigilant in preventing mishaps.

And while the agency has fined more than 140 hospitals to date, more than 200 acute care facilities statewide have never been penalized. Although Rogers did not say that hospitals may be underreporting patient mishaps, she noted that a study commissioned by the CDPH and conducted by UC Davis that is expected to be published later this year will analyze and discuss that issue in greater detail.

One adverse event category that saw a big rise in the last fiscal year was sexual assaults on patients, which reached 37 – up 85% from the 20 reported in fiscal 2011, according to CDPH data.

One such sexual assault cost Placentia Linda Hospital in Placentia its first administrative penalty and a $50,000 fine due to the failure of the chief of its anesthesiology department to forward a report he received of another anesthesiologist witnessed by hospital employees fondling an unconscious female patient. That failure to report led to a second fondling of a patient under circumstances similar to the first incident, according to the CDPH.

That physician, identified by the Orange County Register as 59-year-old Yashwant B. Giri, M.D., was arrested in May 2011 not long after he was reported to authorities after the second incident took place. 

Giri is facing five felony charges. He agreed to stop practicing medicine in lieu of being granted bail on the charges, according to the Medical Board of California.

Four of the penalties disclosed by the CDPH involved patient deaths. Adventist Medical Center in Hanford received its third administrative penalty and a $50,000 fine when a patient admitted for heel surgery overdosed on morphine after the procedure was completed. His advice for self-administering the narcotic had permitted a far larger dose that recommended.

Memorial Medical Center in Modesto received its first administrative penalty and a $50,000 fine when a patient died while undergoing a procedure to pulverize bladder stones. The patient's doctor said he “zoned out” at a time he should have alerted other hospital staff when his heart stopped, according to the CDPH report. Memorial also received a second penalty when a patient underwent an unnecessary implant of a cardiac device as the result of a mixup of medical records.

Santa Clara Valley Medical Center received its third administrative penalty and a $100,000 fine after a patient shortly after becoming disconnected from his cardiac telemetry equipment after a fall. A hospital technician did not follow procedure for alerting other personnel when the patient's vital signs disappeared from their monitor.

St. Mary's Medical Center in San Francisco received two administrative penalties and $175,000 in fines. One incident involved a patient who was given an anti-anxiety medication prior to surgery and died. The anesthesiologist who provided the medication did not follow protocols for monitoring the patient.

UCSF Medical Center received its seventh and eight administrative penalties and $200,000 in fines connected to retained surgical objects in two cancer patients undergoing treatment.

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