Doctors at Sequoia were supposed to remove the patient's appendix, fallopian tubes, and uterus during surgery in February 2016; however, due to a mistake in the hospital's surgical schedule, the patient's ovaries were taken out. The patient, according to the report by the California Department of Public Health, will require lifelong estrogen replacement therapy as a result. The report did not mention the patient's name and age, nor did it mention if the ovaries were removed instead of, or in addition to, the appendix, fallopian tubes, and uterus.
“The care and safety of our patients and staff are the highest priority at Dignity Health Sequoia Hospital and we take this matter very seriously. After self-reporting this event to the CDPH, we fully cooperated during their investigation and immediately took steps to ensure this never happens again, including revising protocols and staff re-education,” said a spokeswoman for Dignity Health, a Northern California health system.
In an announcement by the California Department of Public Health, the agency has stated the fine against Sequoia Hospital is one of 17 civil penalties filed against 14 California hospitals. All of the penalties, which total $1.1 million all in all, concerned incidents that have caused serious injury or death. (Related: Brain Surgeons Can't Tell Left from Right: Third Operating Mistake on Wrong Side of Patient's Head)
Out of the 14 hospitals, four of them, including Sequoia Hospital, are in the San Francisco Bay Area. Two of the hospitals, St. Luke's Campus and Kaiser Foundation Hospital and California Pacific Medical Center, are located in San Francisco. The other, Queen of the Valley Medical Center, is located in Napa.
St. Luke's has been fined $47,452 after a patient felt dizzy and fell out of her bed while under the care of the hospital staff. The patient was not put through the prescribed hourly neurological checks and died despite undergoing emergency brain surgery.
Kaiser Foundation Hospital has been fined $147,000 for two separate incidents in 2015 and 2016 that resulted in the deaths of the patients. In one, a patient receiving dialysis suffered massive blood loss and cardiac arrest after his line disconnected from his catheter. In another, a patient died after their tracheostomy—a surgical procedure to create an airway—was mishandled and a tracheostomy tube cuff valve had been left inflated. A spokeswoman for Kaiser has said: “We sincerely regret that these incidents occurred and extend our sympathy to the families involved. In response to these incidents, and to ensure such situations never occur again, we immediately investigated their root cause, evaluated our processes and implemented systemic improvements and training for our nurses, physicians, and staff.”
Queen of the Valley has been fined $225,000 for three incidents in 2013, in which hospital staff failed to properly track patients' symptoms and dispense correct treatment. Two patients died while the third patient was left in a vegetative state.
The California Department of Public Health, states Rhea Mahbubani of NBCBBayArea.com, is allowed to issue up to $75,000 in fines for the first administrative penalty of a hospital. The second penalty can go up to $100,000, and the third up to $125,000, as well as all subsequent violations within a three-year period. Hospitals that have been penalized have 10 days to appeal, and are required to issue a plan of correction.
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