California health agency works with hospitals to reduce errors

Doctors at Parkview Community Hospital Medical Center in Riverside diagnosed Francisco Torres with a tumor on his kidney and he agreed to have it removed last July. But after the operation, he learned that the surgeon had removed his other healthy kidney, forcing Torres, 72, to undergo a second surgery and become dependent on dialysis.

“I don’t know why this happened, this error,” Torres said.

There were 1,538 such preventable medical errors reported at California hospitals last fiscal year, according to regulators at the state Department of Public Health. The mistakes are referred to as “never events” because they are avoidable, and should “never” happen.

Among the most common errors were bed sores acquired after hospital admission (1,036), retention of a foreign object in a patient (198), death associated with a fall (42) and death during or up to 24 hours after surgery (41).

The state began requiring hospitals to report certain preventable errors in 2007.

Patient advocates argue that such errors increase the cost of healthcare for all Californians.

Anthony Wright, executive director of Health Access, a Sacramento-based nonprofit, said preventable medical errors often lead to expensive corrective surgery, malpractice lawsuits and settlements, raising the cost of healthcare.

“If we can reduce these errors, it will be as big a cost containment as anything else that is being debated as part of health reform,” he said.

However, hospitals say that not all the mistakes reported to the state are their fault, and that a final review will determine that some of them are non-hospital related.

Of 1,224 errors reported in the year before last, investigators eventually faulted hospitals for 480 of them. An additional 281 incidents were transferred to other state officials to investigate because they did not fit the 28 categories of reportable errors cited in the law. Eighty-five of the errors are still under investigation. “It’s hard to draw conclusions yet” about last year’s numbers, said Debby Rogers, vice president of quality and emergency services at the California Hospital Assn., which represents about 430 hospitals. “Some of these things are not always preventable.”

Rogers said hospital officials were still learning which errors they are required to report, which may lead to both over- and underreporting.

Hospitals that the state faults can be fined: $50,000 for the first violation, $75,000 for the second and $100,000 for the third or subsequent violations. Errors that occurred in or before 2008 carry a $25,000 fine. Hospitals can appeal the fine by requesting a hearing, but even those that appeal must submit a plan of correction to the state.

Public health officials have so far issued 134 fines to 90 hospitals, according to Kathleen Billingsley, deputy director of the public health department’s Center for Health Care Quality. Thirty-seven of the fines have been appealed, Billingsley said, and the state has collected $2.8 million.

Marina del Rey Hospital was fined $25,000 in January in connection with the treatment of Patricia Lappin. The 75-year-old El Segundo resident suffered a heart attack and had to be placed on a ventilator in May 2007 after nurses in the hospital’s intensive care unit failed to notice her oxygen levels had dropped.

About a week later, her family removed her from the ventilator and she died. Lappin’s daughter, Lisa Aznar, complained to regulators, prompting a probe.

Aznar, 49, an elementary school teacher, said she felt vindicated by the investigation. “I wasn’t seeking revenge, I just wanted redress,” Aznar said.

Regulators plan to release a report in coming months analyzing statewide trends in preventable medical errors, Billingsley said. They also plan to spend $800,000 of the fines collected from hospitals this year on research and prevention of foreign objects left behind during surgery, she said. Last year, the department spent $300,000 of the fines on assessing, among other things, whether hospitals are underreporting errors, she said.

Parkview Community Hospital reported the Torres kidney error to the state the day after his surgery, state records show. Investigators visited the hospital, interviewed staff and found the hospital had erred. His surgeon, Hakan Wahlstrom, had not had hospital privileges to perform kidney surgery since 2005, investigators wrote in their report. Torres, a Mexican immigrant who does not speak or read English, had not had his condition or the surgical consent forms explained to him by hospital staff in Spanish, so he could not have known that the wrong kidney had been marked for removal, investigators wrote.

The hospital submitted a plan of correction to regulators in January noting that it had improved translation services, verification that surgery is performed on the correct body part and monitoring of surgeons’ credentials.

Following the Torres surgery, the hospital issued Wahlstrom temporary surgery privileges, according to the plan of correction. Regulators are still considering whether to fine the hospital in connection with the error.

Torres, a retired factory technician, sued the hospital and his surgeon for medical negligence in August.

His daughter, Lucy Fontana, said the lawsuit was an effort to recoup some of the cost of her father’s care.

“That kind of mistake shouldn’t happen in this country -- we’re supposed to be advanced,” Fontana, 47, said.