Bay Area Medical Mistakes: The Facts

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    NEWSLETTERS

    TK

    This is not the kind of news you want to hear, especially if you have a visit to a hospital in your future.

    A list of hospital mistakes and the fines that came with them was just released to the public.

    They range from leaving a sponge inside a cancer patient long enough for it to bore through her vagina, to a medicine mix up that ended in brain death.  

    The California Department of Public Health fined at total of 13 hospitals $650,000 for mistakes made in 2008-2009. 

    The following stories are some of the incidents at Bay Area hospitals.  They show how a simple mistake can cost a life.

    The report showed Santa Clara Valley Medical Center in San Jose had a mistake that lead to the death of a patient who was sent to the ER after going to an Urgent Care facility complaining of dizziness and fatigue.

    The paperwork the patient carried with him showed a low hemoglobin count that should have given him a more urgent status, but the nurse who traiged the patient said he thought a line drawn under the hemoglobin number meant that the result was incorrect. 

    The patient was later found in the lobby unconscious and attempts of resuscitation failed. The patient died.

    The report said emergency room start at the Kaiser Foundation Hospital in Oakland failed to double-check medication orders on a drug order sent from the pharmacy. The error resulted in a 90-year-old patient receiving a variety of blood pressure and stomach ulcer medications and potassium chloride intended for a different patient.

    After getting the wrong medicine the patient went into severe respiratory distress. A physician interviewed by the investigators "said he could not rule out that the blood pressure medications administered in error caused the severe change in Patient A."

    The man had to be intubated and put on a ventilator. Tests show he lost brain function.

    Surgeons at San Francisco General left a 4-inch by 8-inch piece of gauze sponge inside a cancer patient. The mistake wasn't found for three months and only after the patient returned to the hospital complaining of a foul-smelling discharge.

    The report said the sponge had "tunneled through her abdominal wall into her vagina."

    One nurse relieving another at the end of the surgery seemed to when the mistake happened.

    The facilities that were fined are now required to implement a plan of correction to prevent similar incidents in the future.