POWAY: Hospital fined $25K for "immediate jeopardy" incidents
Faulty machine allowed three patients to regain consciousness during surgery
By ANDREA MOSS - Staff Writer | ∞
POWAY ---- The state has fined Pomerado Hospital $25,000 for a "preventable mistake" that allowed three of the hospital's patients to regain at least partial consciousness while undergoing surgery.
The local hospital is one of 18 on a list of medical facilities hit with fines by the California Department of Public Health. The agency released the list Friday and posted it on the department's Web site Monday.
Department of Public Health spokeswoman Suanne Buggy said Monday that the fines were levied after department investigators confirmed reports of "immediate jeopardy incidents," or those that cause or could cause serious injury or death.
The patients involved in the Pomerado Hospital incidents ---- which occurred after the hospital's staff used a faulty anesthesia machine ---- did not die. They were not identified.
Buggy said the agency considers any immediate jeopardy incident to be a "very, very serious" matter.
"When that happens, it is incumbent on the facility to fix the problem immediately," she said. "And we work with the hospital to make sure that, whatever it was, was resolved."
Palomar Pomerado Health, a public health care district, owns and operates Pomerado Hospital.
Opal Reinbold, chief quality officer for the district, said hospital officials notified the Department of Public Health after the three patients reported "surgical awareness," including feeling pain, after leaving the hospital's operating room March 31.
The first patient involved did not immediately say anything about the problem, Reinbold said, so the hospital's staff continued to use the anesthesia machine without realizing there was a problem. By the time the second patient regained enough consciousness to report surgical awareness, the third patient's surgery had been completed, she said.
"There was absolutely no indication that this was occurring during the surgery," Reinbold said. "When we knew that we had an issue, we took that anesthesia machine down and we locked it in the administrator's office so there was no chance that anybody could get to it (or) use it."
The hospital replaced all of the machine's parts before it was used again, she said. Pomerado Hospital also provided the three patients and their families with whatever support they asked for, including social workers and psychiatrists, Reinbold said.
"Our major concern, always, when something unusual occurs always is the patient and their family," she said. "It truly is. There's nothing else that I could emphasize more."
The state began fining hospitals for immediate jeopardy incidents after a law authorizing the Department of Public Health to do so took effect Jan. 1, 2007. Buggy said she believed this was the first time Pomerado Hospital faced such a penalty.
Three other San Diego-area hospitals ---- Scripps Green Hospital in La Jolla, San Diego-based Promise Hospital (previously known as Villa View Community Hospital) and Sharp Grossmont Hospital in La Mesa ---- also are on the latest list of facilities fined for immediate jeopardy incidents.
Visit cdph.ca.gov for information.
Contact staff writer Andrea Moss at (760) 739-6654 or amoss@nctimes.com.
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Ok wrote on Aug 18, 2008 8:16 PM:Here we go with another Covert bashing thread.
Thank you wrote on Aug 19, 2008 8:29 AM:The fining by a State Department really helps our health care costs. Idiots, these fines just come back to the patients one way or another!!
At least the hospital wrote on Aug 19, 2008 8:37 AM:admitted there were problems and reported them. It could have been a coverup but was not, thankfully. Thank God everyone is ok.
escondeto wrote on Aug 19, 2008 8:41 AM:another reason why the incumbants on the board do not need to be re elected. its obvious the administration is crumbling. lets vote some new member in.
Boat wrote on Aug 19, 2008 8:50 AM:I was a Respiratory Therapist for many years after I got out of the Navy. There is a small electronic device that anestheologists use to determine if the patient is "under." It uses two electrodes that are placed on the ulna (forearm bone) then the device delivers a series of shocks. You watch the fingers for twitching. The amount of twitching will tell you how far "down" the patient is. On the face of this story it sounds to me like they didn't use this device. It was used all the time in the O.R. & ICU where I worked. We tried it on each other so we would know what it was like - let me tell you - it delivered quite a jolt - I came off the floor by about six feet.
Also, we had two technicians whose job it was to service the anesthesia machines so things like this never happened. They were highly trained & very competent. Makes me wonder who is doing that job at Pomerado.
The Least of PPHs Worries wrote on Aug 19, 2008 9:13 AM:The $25,000 fine is nothing compared to what PPH will face when these 3 patients find attorneys. Is there any guarantee that the PPH administration and board will run the "Hospital of the Future" any better? I doubt it.
RNOR wrote on Aug 19, 2008 1:57 PM:To Boat- The 'twitch monitor' that you are speaking about it also called a 'nerve stimulator' the purpose of this tool is to measure the effects of the paralyzing agents- unfortunately it doesnt measure how 'deep' the patient is. There is a monitor called the BIS monitor; it is the only tool that truly measures how deep the patient is.
I do agree with you though in questioning who is doing what here!
To Boat and RNOR wrote on Aug 19, 2008 4:16 PM:The small electronic device that you are referring to is a nerve stimulator and it checks a patients strength...nothing else. It does not determine level of consciousness.
To RNOR the BIS monitor has proven to be a very faulty tool, and repeatedly interprets muscle paralysis as sedation. The two are very different things. This is why the BIS monitor is quickly falling out of favor.
At this hospital, it is my understanding that all anesthetics are performed by board certified or board eligible anesthesiologists (doctors). This is obviously an extremely unfortunate event apparently related to malfunctioning equipment.
For the record, the quoted incidence of some form of intraoperative awareness is 1 in 2000. It is rare, but unfortunately it happens. Afterall, this is surgery. It is not risk free.
RE To RNOR wrote on Aug 19, 2008 9:43 PM:It seems that we both agree that the PNS measures muscle paralysis and does not measure or determine level of consciousness. My knowledge of BIS is based data from JCAHO SEA #32 (2004). Based on this, awareness occurs in 1-2 cases per 1000 and that use of BIS may be associated with reduction in the incidence of awareness during GA.Yes I agree that it is rare and in this case it is a result of malfunctioning equipment; but would you want that to happen to one of your family members? And if there was a tool to help reduce the risk, whould you want it to be used on you or your family member?
scared wrote on Aug 21, 2008 12:16 PM:There are so many things that happen in hospitals that we are not told about. If you knew the truth it would make you want to stay home instead. The big problem is...people don't care that much. I say this from a source that knows the insides of these work places. Handing out fines is not the answer, it's hiring the right people who are intelligent and who care.
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