Oct 25, 2013

The Wrong Kidney Removed and Life in the OR at Sharp Memorial San Diego

Cut time:  rushing......why isn't the patient in the room?

Did we do the time out?  Did everyone listen?  Did the surgeon listen?

The Wrong Kidney Removed and Life in the OR at Sharp Memorial San Diego

Seriously, life at Memorial, perhaps the Sharp OR will now shift their focus to patient safety instead of rushing for the surgeon's convenience.

copied from nbcsandiego.com..............

2 San Diego Hospitals Fined by California Dept. of Public Health

One facility was fined for failing to prevent a patient's fatal fall, while the other was fined for removing the wrong kidney from a patient

By Monica Garske
|  Thursday, Oct 24, 2013  |  Updated 9:21 PM PDT
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2 San Diego Hospitals Slapped with Fines
Two San Diego-area hospitals were fined by the California Department of Public Health (CDPH) on Thursday after investigations found that one facility failed to prevent a patient's fatal fall, while staff at the other facility removed the wrong kidney from a patient during surgery.
According to the CDPH, penalties were issued to Alvarado Hospital Medical Center and Sharp Memorial Hospital in San Diego County because the facilities’ non-compliance with licensing requirements likely caused serious injury or death to patients.
According to a report filed by the CDPH, Alvarado Hospital Medical Center was given a $50,000 penalty for failure to ensure the health and safety of a patient when the hospital did not follow established policies and procedures regarding fall prevention.
The report says a registered nurse turned off a bed alarm for a high fall-risk patient and the patient fell out of her bed, hit her head and suffered a bleed into her brain tissue stemming from the fall. The patient died the next day.
An investigation into the incident was launched in February 2012. In the end, the investigation determined that failure to prevent the fall resulted in the patient’s death, according to the documents.
The CDPH said this is Alvarado Hospital Medical Center’s first administrative penalty.
Meanwhile, Sharp Memorial Hospital, San Diego, was issued $100,000 penalty because the hospital failed to ensure the health and safety of a patient when it didn’t follow surgical policies and procedures.
A report filed by the CDPH says medical staff incorrectly removed the left kidney of a patient during a surgical procedure. The 53-year-old patient had a suspected cancerous mass in his right kidney, but staffers failed to correctly identify the surgical site on the day of the operation, ultimately removing the wrong kidney.
“The failed surgical team failed to have any of the relevant images of the kidney(s) available and displayed during any part of the surgical procedure,” the report states.
The patient survived, but the hospital is still being fined for failure to prevent the deficiencies, which caused serious injury to the patient. The CDPH says this is the hospital's fourth administrative penalty.
The local hospitals are just two out of nine California medical facilities fined by the CDPH on Thursday.
Other facilities include: St. Jude Medical Center, Fullerton, in Orange County; Antelope Valley Hospital in Los Angeles County; Community Regional Medical Center in Fresno County; Community Regional Medical Center in Fresno; LAC/Harbor-UCLA Medical Center, Torrance, in Los Angeles County; Mercy Medical Center in Merced County; Mission Hospital Regional Medical Center, Mission Viejo, in Orange County; Santa Clara Valley Medical Center, San Jose, in Santa Clara County.
The CDPH says administrative penalties are issued under authority granted by Health and Safety Code section 1280.1. A penalty carries a fine of $50,000 for the first violation, $75,00 for the second and $100,00 for the third or subsequent violation.

Source: http://www.nbcsandiego.com/news/local/2-San-Diego-Hospitals-Fined-by-California-Dept-of-Public-Health-229202551.html#ixzz2ikTYaNSQ

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