Oakland Hospital Fined Following Surgical Error





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Alta Bates Summit Medical Center's Summit campus in Oakland was one of 11 hospitals fined by the California Department of Public Health following a March investigation of a surgical mistake at the hospital, according to a department statement released Thursday.

The $25,000 fine was issued after the hospital failed to properly account for surgical instruments during a heart operation in December 2008.

According to a department document, a 79-year-old male patient underwent heart valve repair surgery at the hospital on Dec. 11. During the course of the operation, a ring sizer-a coin-sized instrument used to measure the heart valve opening-was left inside the patient's heart sac.

"In this, the most human of settings, there was an error," said John Gentile, Alta Bates Summit's Vice President of Medical Affairs, in a statement. "Our greatest priority is, and always will be, patient safety."

After suffering from post-operative breathing and heart rate problems, the patient underwent a pair of CT scans that revealed the foreign body. The patient then received a second heart surgery to remove the object, as well as a tracheostomy to address breathing problems. When the ring sizer was removed, the patient suffered acute kidney failure but survived the operation.

The error occurred in part because of a staff change during the operation. According to the report, a scrub technician had noticed that a ring sizer was missing while looking at his instrument tray. However, after being relieved by a nurse for a lunch break, the technician incorrectly assumed the object had been found.

The hospital, which reported the incident to the department, began an immediate review process per hospital policy to prevent further accidents.

Spokesperson Ralph Montano said department-approved changes were already in place before the hospital received the fine.

"The administrative penalty is the last step in a process," Montano said. "(Alta Bates Summit has) already taken steps to make sure that this does not happen again."

The fine, the first of its kind issued to the hospital, will be put into a fund for programs that will improve patient safety and health care quality in California, Montano said.

According to the department Web site, Alta Bates Summit is the third Alameda County hospital to receive an administrative penalty from the

department.

To date, the department has issued a total of 115 administrative penalties to 80 different California hospitals. The department first started issuing the penalties in October 2007, and has since assessed $2.87 million, of which around $1.6 million has been collected, according to Montano.

In 2004, Alta Bates Summit received a negative audit from hospital-industry watchdog group The Joint Commission on Accreditation of Healthcare Organizations, according to a Daily Californian article from Nov. 16, 2004.

At the time, the hospital was at risk of losing its accreditation from the commission, which health organizations need for funding, insurance purposes and recruiting health care professionals, said commission spokesperson Charlene Hill in the article. According to the commission's Web site, however, Alta Bates Summit is currently accredited.

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Contact Michael Garcia at [email protected]



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