After errors causing the deaths of two patients, in 2007 California passed tough laws backed by substantial fines requiring hospitals to promptly report serious medical errors. California is one of only five states with laws requiring public reporting of errors including the health facilities responsible. -DB
San Francisco Chronicle
August 9, 2009
By Lance Williams
In the summer of 2005, a 12-year-old girl with pneumonia died at the Kaiser hospital in Santa Clara when nurses accidentally gave her a fatal dose of the powerful stimulant epinephrine.
A month later, at the Kaiser hospital in nearby San Jose, a 21-year-old cancer patient was killed when his doctor mistakenly injected his spine with the wrong chemotherapy drug.
The fatal mistakes moved state Sen. Elaine Alquist, D-San Jose, to write three related measures that have transformed California’s system for monitoring medical errors in hospitals – and toughened fines when egregious mistakes occur.
Under the terms of the new laws, hospitals must make prompt reports to the state health department whenever serious medical errors occur. Within 48 hours, the health department must investigate.
For the first time, the laws have imposed a sense of urgency about dealing with bad hospital mistakes. Before the laws went into effect in 2007, the state set no hard deadlines for reporting or investigating hospital errors. As a result, hospitals often delayed reporting egregious mistakes for months, and many errors were never investigated at all, experts say.
The new laws also dramatically increased fines for hospital errors that posed “an immediate jeopardy to the health or safety of a patient.” Before, fines were as little as $50 per incident. The new laws increased fines to $25,000 per incident starting in 2007, then raised them to $100,000 this year.
Alquist said the deaths in hospitals in her district sensitized her to the chronic problem of medical errors statewide.
“People are dying when they shouldn’t be dying,” she said. “The wrong limb is cut off. Patients are administered the wrong medications, or they’re given a huge overdose, or – and it’s really spooky – people stay awake during surgery” because anesthetic is improperly administered.
“This should not be happening in California,” she said.
7 fines in 2 years
In the two years since the measures went into effect, the state imposed 87 fines of $25,000 each on hospitals where serious medical errors had occurred, records show.
Most fines were levied because patients were given the wrong amount or type of medication. But hospitals also were fined for incidents in which patients remained awake during surgery, had difficulty breathing because of ventilator malfunctions, or went home after surgery with a towel or other foreign object sutured inside them by mistake.
In the Bay Area, fines were levied in the deaths of five patients.
Doctors Medical Center in San Pablo was fined for failing to provide proper treatment to a diabetic patient who died of hypoglycemia. It was fined again because a nurse improperly inserted an IV catheter into a patient’s vein; an air embolism caused a fatal heart attack.
Washington Hospital in Fremont was fined because an elderly heart patient died when nurses mistakenly gave her methadone that had been prescribed for somebody else. Kaiser hospital in San Jose was fined because a patient with diabetes and dangerously high blood sugar died untreated in the emergency room.
And the Kaiser hospital in Santa Clara was fined after a premature baby was given an overdose of two medications. The overdoses occurred because the substances had been improperly labeled during repackaging by the hospital’s pharmacy. The baby died.
In all, hospitals have reported more than 1,000 errors since the laws went into effect. The statute specifies 27 types of hospital errors that must be reported.
Experts call them “never events” because they are events with such serious consequences that experts say they should never happen. The list was compiled for Alquist by the National Quality Forum, a health care lobby.
High error rate in s.f.
According to state records, San Francisco’s hospitals have a high rate of medical errors – 253 “adverse events” over a two-year period ending in April, second only to those in Los Angeles County, which reported 392 events.
When the totals are adjusted for hospital population, San Francisco had the highest reported medical error rate in California – 1 event for every 282 patients discharged per year.
Some experts, however, suspect the data simply give a picture of how seriously hospitals take their reporting responsibilities.
Failure to report an error brings fines of $100 per day. Hospitals that fail to report can also face loss of their licenses.
But in fact, no fines have been levied for late reporting.
According to state records, of California’s 58 counties, 14 reported no hospital errors at all in the past two years. The most populous among them was Merced County in the Central Valley.
Copyright 2009 Hearst Communications Inc.