(MintPress)— After leaving medical equipment inside of several patients after surgery, failing to detect symptoms of fetal distress resulting in the stillborn birth of a baby and the sexual assault of a patient by a nurse, 13 hospitals in California were fined for healthcare violations.
The California Department of Public Health (CDPH) has released its list of hospitals they have fined for safety violations earlier this week.
While events like this may shock the public, the fact that it’s unknown how many such events happen nationally each year in the United States because there is no centralized reporting system to monitor such situations is also alarming.
California tallies violations
California regulators say Rancho Springs Medical Center in Murietta, Calif., was fined $100,000 for violations that led to an infant’s death. The hospital is accused of failing to take the necessary precautions when the fetal heart rate of the child steadily declined.
The Motion Picture and Television Hospital in Woodland Hills, Calif., was fined $50,000 after it was discovered hospital staff left a surgical sponge inside a patient.
Chapman Medical Center in Orange, Calif., was fined $75,000 stemming from an incident involving a patient who went to the emergency room complaining of arm pain. After she was administered a narcotic painkiller, a male nurse kissed and fondled her and exposed himself, according to a state complaint.
CDPH spokesman Ralph Montano said in an interview with MintPress that the agency issues such reports periodically throughout the year.
The agency finds out about such incidents in several different ways. Patients, families of patients, nurses, doctors and other hospital staff members can file an anonymous complaint with the agency, which will trigger a surprise inspection. Montano said many of the violations are found in that manner.
However, the hospitals are also visited annually by the agency for inspections, which can also turn up violations. Federal law requires that a hospital be inspected at least every 18 months. Montano acknowledged that it’s less likely state officials find violations in this way.
In all, the 13 hospitals named in the release this week were imposed a combined $825,000 in penalties. The facilities have the right of appeal and do not have to pay the fines until any appeals are resolved.
State law in California pioneers system for reporting violations
California law requires all California hospitals to report the occurrence of any of the 28 so-called “never events” to the CDPH.
These include 27 specific events such as wrong surgery on a patient, retention of a foreign object in a patient’s body following surgery, artificial insemination of a patient with the wrong donor sperm or donor egg, discharging an infant to the wrong person, surgical or medication errors resulting in death and sexual assault of a patient on the grounds of a healthcare facility.
It also includes a category for reporting “an adverse event or series of adverse events that cause the death or serious disability of a patient.” The law requires hospitals to report within five days after the hospital detects the adverse event, and the Department of Public Health then must perform an on-site inspection within 48 hours of the report.
Montano said when the law went into California books in 2006, it was the first of its kind in the nation. He also said the CDPH has 600 surveyors in charge of completing hospital inspections.
Since 2007, California, the most populous state in the nation, has issued a total of 224 administrative penalties to 129 hospitals in the state after finding violations which resulted in serious injury or death to patients.
The state has 450 general acute care hospitals and 250 psychiatric hospitals.
Other states may keep track of such events occurring in medical facilities, but since there is no national body assigned to maintain records of such incidents, experts say they have no way of knowing how many are occurring per year across the U.S.
In Minnesota, the state publicly reports adverse events by hospital online, and in Illinois there has been an effort to enact a similar measure. These states are part of a small but growing number of states working towards transparency.
Under a 2005 federal law, the Patient Safety and Quality Improvement Act, hospitals may elect to report errors or other problems to patient safety organizations, but these reports are kept confidential.
Need for medical error reporting uncovered
In January, a study released by the Office of the Inspector General (OIG) of the Department of Health and Human Services (HHS) found that hospital employees are only reporting 14 percent of all medical errors and usually don’t change their practices to prevent future harm to patients.
“One in four hospital patients are harmed by medical errors and infections, which translates to about 9 million people each year,” says Lisa McGiffert, Director of Consumers Union’s Safe Patient Project. “Too many hospitals are doing a poor job of tracking preventable infections and medical errors and making the changes necessary to keep patients safe. It’s time that hospitals make patient safety a higher priority.”
The OIG report recommends that the Centers for Medicare and Medicaid Services (CMS) provide hospitals with a standard list of medical errors that should be tracked and reported to the agency.
“Hospitals should be pushed to do a better job at tracking medical harm, but public reporting is what drives change and the public should have access to this critical information,” said McGiffert. “The solutions arrived at in this report take us down the tired and worn out path of secret reporting of medical harm.”
In 2002, The National Quality Forum (NQF), a Washington, D.C.-based nonprofit healthcare advocacy group, created and endorsed a list of serious reportable events (SREs) to increase public accountability and consumer access to critical information about healthcare performance. There are 29 events and each is classified under 1 of 7 categories: surgical, product of device, patient protection, care management, environment, radiologic or criminal.
The organization has said that while 26 states and the District of Columbia have enacted reporting systems to help practitioners identify and learn from such events, and most states incorporate some portion of the NQF’s list of events into their approach toward reporting patient safety, “the variation among states in their approach toward reporting patient safety events affects efforts to improve from these adverse events.”