We’ve all heard that classic movie line: “Failure is not an option.” And don’t forget those admonitions from mom or dad reminding you that there would be consequences for your epic fails. It turns out that the quote from the Apollo 13 blockbuster film and that archetypal parental rebuke are both rooted in a very stark reality: bad things can and do happen when certain standards are not met.
Last week, we brought you a few examples of the Joint Commission’s new safety standards that are scheduled to go into effect this summer. This week, we received another reminder of why such emphases on safety are needed. This time, the consequences of failure meant the life of a patient.
The Ultimate Consequence
According to Becker’s Clinical Leadership and Infection Control, a regional medical center located in the San Joaquin Valley of California has just been assessed its fifth fine in four years by the State of California. The latest assessment comes as a result of a failure in safety controls that led to the death of a patient. Specifically, a flat metal object used to hold back tissue during surgery was left inside the abdomen of a 70-year-old patient. After complaining of pain following the surgery, she underwent a second procedure to remove the object, but expired following this subsequent surgery.
The Fresno Bee reported on May 19 that, following the state’s review of the incident, the facility was fined $78,750. The fine is reportedly the highest in state history against a hospital for the category of “immediate jeopardy.” Notably, it is the second time the facility has been fined for leaving an object in a patient since 2019, according to the Bee.
A History of Safety Breaches
According to data from the California Department of Public Health, the medical center in question has been fined a total of five times for various procedural violations since 2015. It was fined a total of $92,000 in 2015 for a “medical information breach” related to administrative policies. Specifically related to immediate jeopardy fines, the California facility has so far amassed a total of $221,000 in penalties for these events that occurred in 2019, 2021, 2022 and 2023, according to the state’s official data. In 2022, the fine was for operating on the incorrect body part of a patient, according to the local news outlet. The $221,000 does not include the $92,000 amount.
Not the Only Facility
To be fair, the heavily fined medical center is not the only one in the region to be hit with assessments from the state for putting patients in danger. Two other local medical centers were also fined by the California Department of Public Health over adverse events in recent years. This raises an obvious point, like that proverbial elephant in the room: If these three medical centers—all located in the same geographical area—are being fined for failure to adhere to critical patient safety standards, is this not indicative of similar breaches that must be occurring in facilities across the country? This is why the Joint Commission’s National Patient Safety Goals (NPSGs), which we briefly addressed in our last alert, are not to be taken lightly. They are not only meant to enhance efficiencies in patient care, but they are designed to help hospitals avoid life-threatening incidents.
Having said all this, it is a bit curious that the NPSGs slated for implementation this July do not specifically address the situation that caused the death of the patient previously referenced. While the Joint Commission’s safety standards cover a wide range of risk areas, it is clear that not every risk is addressed by the surveying organization. It will therefore be up to each individual acute care hospital to be proactive in installing preventative measures, including multiple cross-checks, so that all foreign materials not meant to remain in the patient’s body post-surgery are accounted for.
In the end, the situation that led to the patient’s death, referenced above, was the result of human error. But such errors need never occur if the hospital puts into place protocols that are stressed by the administration as unbending and overriding. For example, there could be a protocol that at least two individuals in each surgical session are tasked with documenting each item that is placed in the body, as well as confirming their removal before closing the surgical field. Cross-communication, orally, in real time, may also facilitate a level of certainty that all such materials have been removed. This link provides a revised statement by the American College of Surgeons concerning steps that hospitals should take to mitigate retained surgical items: The Prevention of Unintentionally Retained Surgical Items After Surgery | ACS (facs.org).
Each facility will have to determine their own protocols in this area, in addition to following existing medical and regulatory rules. If the rules are not sufficiently robust, then hospitals should take the initiative to set the bar even higher. The consequences of failing to maintain scrupulous safety standards can be severe: fines, lawsuits and, most significantly, serious harm to the individual patient.
With best wishes,
Chris Martin
Senior Vice President—BPO