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Surgery mistake costs Fresno Surgical Hospital

- The Fresno Bee

Friday, Dec. 09, 2011 | 11:20 AM

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Fresno Surgical Hospital was slapped with a $50,000 fine after surgical gauze was left inside a patient following surgery, the state Department of Public Health announced Thursday.

The fine was one of 14 levied against California hospitals. The northeast Fresno surgical center was the only Central Valley hospital fined.

The incident occurred during a hysterectomy in 2009, state reports said.

The patient, who was not named, had "gauze sponge" inside her for eight months after surgery and needed additional prescription drugs and surgery because of the error.

A second surgery to remove the sponge took place at another hospital, the state report said.

Investigators said the woman told them she could not recover after the first surgery and continued to suffer from pain, weakness and infections. She continues to take medication for a weak bladder and incontinence because of the error, the state said.

"I feel like I have been robbed of my life having to live with this," she told investigators in July.

The surgeon who performed the first surgery said he was never told a sponge count was incorrect.

The hospital informed the patient about the mishap before reporting it to the state as required by law.

The sponge was found to be the source of the woman's infections, the state said.

Citing patient-privacy laws, hospital officials declined comment on the state fine.

"We remain committed to supporting the health and well-being of our patients and their families throughout the entire operative experience," Kristine Kassahn, the hospital's chief executive officer, said in a prepared statement.

Under a 2007 law, hospitals are required to self-report errors to the California Department of Public Health in cases that could cause serious injury or death to a patient or for failure to follow state licensing guidelines, said Pam Dickfoss, acting deputy director of the Center for Health Care Quality in the state Department of Public Health.

The hospital also must issue a report outlining its plans to keep such problems from recurring.

In its "plan of correction," hospital officials said they would provide more accurate counts for both sponges and needles. Those counts will be done out loud by two people, one a registered nurse.

The hospital also now requires all operating room staff to view a training video about patient safety and the dangers of leaving objects inside patients after surgery, the plan said.

Leaving objects inside patients following surgery is the second-most-common reason for hospital fines, California Department of Public Health records show.

It has occurred 52 times since 2007 among 214 documented penalties where fines have been assessed. It is exceeded only by errors made in dispensing medication, which occurred 53 times since 2007.

Since the self-reporting program started in 2007, the state has assessed more than $7.85 million in fines and collected more than $5.1 million, Dickfoss said.

During that time, Saint Agnes Medical Center in Fresno was fined three times and Hanford Community Medical Center fined twice.

Clovis Community Medical Center and Kaiser Permanente Medical Center in Fresno have each been fined once.

Money from the penalties is funneled into hospital quality improvement programs, she said.


The reporter can be reached at mbenjamin@fresnobee.com or (559) 441-6166.

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