Health Watch

Two Valley hospitals face fines for improper procedures

Wednesday, February 06, 2013

Two Valley hospitals have been cited by the California Department of Public Health for failing to follow the rules on patient care.

The Fresno Surgical Hospital was fined after a surgeon operated on the wrong leg. The Adventist Medical Center in Hanford was fined after a patient died from a morphine overdose.

In the case of Adventist Medical Center in Hanford, the patient had surgery on his heel. The state says the hospital failed to have proper procedures in place for using what's called a PCA pump. The pump allows the patient to push a button to get a dose of morphine, through an IV. The state says the dosage was too high, and the staff didn't properly monitor the patient. A pulse oximeter, a piece equipment that could have alerted nurses he was not breathing properly was not hooked up. He overdosed on morphine and was found dead in his room 9 hours after the procedure.

The finding stated:

The facility failed to have a PCA protocol based on professional standards of practice. Pharmacy review failed to flag the high PCA dose. The staff failed to assess pain and assess respiratory and neurologic status. These failures resulted in the death of patient due to acute morphine overdose. Adventist Medical Center was fined 50 thousand dollars. It is the medical centers third administrative penalty.

In the case of the Fresno Surgical Hospital, a patient went in for surgery on his left knee but the doctor operated on the right. The report says the knee wasn't marked before the procedure and the surgical staff failed to do a verbal double check before cutting.

In the states terms they failed to follow the "Universal protocol for preventing wrong site surgery."

After the surgery the report from the state says the surgeon asked: "Which knee did I operate on." When he was told the right knee. He wheeled the patient back in and did the left, which was the correct knee.

The Fresno Surgery Hospital was fined $75 thousand dollars. It was their third administrative penalty. The hospital responded saying the issues have been corrected and that: "The Fresno Surgical Hospital places a high priority on patient care and is constantly trying to improve."

ABC30 left phone messages for the public information person at Adventist Medical Center but have not received a response.

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fresno, fresno county, health watch, gene haagenson
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