Two San Francisco hospitals and one Petaluma hospital are among 12 medical centers that have been slapped with administrative penalties by the California Department of Public Health for violations of health code ranging from improper medication distribution to leaving foreign objects inside surgery patients.
The 14 penalties doled out Friday – which were for offenses committed in 2008, 2009, and 2010 – total about $525,000, Assistant Deputy Director Pamela Dickfoss said.
Most of the hospitals in violation were located in Southern California, but three Bay Area hospitals racked up more than a quarter of a million dollars worth of fees, according to the department.
The Petaluma Valley Hospital at 400 N. McDowell Blvd. in Petaluma received a $50,000 penalty for endangering the health and safety of patients during surgical procedures, the CDPH said.
In San Francisco, the California Pacific Medical Center at 2333 Buchanan St. and the University of California, San Francisco Medical Center at 505 Parnassus Ave. each received two penalties from CDPH totaling $175,000 and $50,000 respectively, the department said.
Both of CPMC’s violations were failure to follow “surgical policies and procedures,” according to the CDPH report. One of the two charges against the UCSF hospital is for the same charge.
Kathleen Billingsly, the deputy director of the CDPH, said in a teleconference Friday morning that at least one of CPMC’s surgical violations was retention of a foreign object in a patient.
At least eight of the 14 violations announced Friday were for the forgetting of a foreign object, ranging from drill bits to towels, inside a patient receiving surgery, Billingsly said.
Three hospitals received penalties for failure to follow policies and procedures for the safe distribution and administration of medication, including the medical center at UCSF, according to the department.
Improper distribution of medication is the most commonly penalized hospital adverse event, according to CDPH spokesman Ralph Montano.
Friday’s penalties against CPMC and UCSF were not their first, according to the department’s records. CPMC received its first offense in early January 2009, again for errors committed during surgery, Montano said.
The first two offenses for which the UCSF Medical Center was penalized were found in 2007 and 2008, and both related to an error in the distribution of medication to patients, according to the department.
Dickfoss said the department is “taking a proactive approach in addressing this problem,” beginning with the administrative penalties against hospitals responsible for such illicit implantation.
The CDPH has also ensured through legislation that $800,000 from the state budget will be allocated toward reducing foreign object implantation during surgery, Dickfoss said.
Billingsly said that expenditure will be spent either by implementing a statewide educational effort about retention of foreign objects in surgery patients or by carrying out “a very specific intervention” in an area where the problem is rampant.
Another option for reducing the risk to surgery patients is focusing attention on what practices and procedures have worked best for hospitals who do not frequently commit this error, and strengthening the lines of communication to spread those best practices to other hospitals, Billingsly said.
Dickfoss said she believes the financial penalties are making a difference in hospitals statewide because the facilities “have taken this very seriously.”
She said data collected through the issuance of penalties is “compiled and compared” to find ways to reduce errors in the long term.
“We think the attention given to administrative penalties is definitely making a difference,” she said. “What we’ve seen is an aggressive effort in hospitals to reduce (medical errors).”
This is the 12th round of administrative penalties to be issued to hospitals throughout the state since the department received the legislative right to do so in 2007, Dickfoss said.
The department issues penalties when it is determined that a hospital’s noncompliance with licensing requirements has caused, or was likely to cause, serious injury or death to patients.
In the past three years, 170 penalties have been administered to 112 hospitals throughout California, Dickfoss said. The fees totaled $4.8 million, of which $3.65 million has been collected.
Another 39 penalties are in various stages of an appeals process, she said.
Kyveli Diener, Bay City News