Showing posts with label Sharp Healthcare fined for removing wrong kidney. Show all posts
Showing posts with label Sharp Healthcare fined for removing wrong kidney. Show all posts

Oct 26, 2013

Oops: The Wrong Kidney Removed at Sharp





Don't be late and don't make a mistake......navigating the rough waters at Sharp Memorial OR.  Why isn't the patient in the room?  What's the hold up?  What time will the patient be in the room?  Has Sharp learned it's lesson.........when will the place listen to the nurses or will the focus continue to remain on the very rushy happiness of these wild, crazy and angry narcissistic surgeons.  Hey, will nurses ever be able to talk or will they have to constantly regurgitate the current mantra......right, sharp is the greatest place to work in town......or whatever the latest concoction of diplomatic propaganda they have created.  Now, if you don't think it and say it.........oops, your future might be in jeopardy...........copied from the UT:...............cl


Sharp fined for botched kidney removal

Sharp Memorial Hospital.
Sharp Memorial Hospital. — K.C. Alfred

 — The state fined two local hospitals Thursday for preventable errors that led to one patient’s death and caused another to rely on dialysis for the rest of his life.
The California Department of Public Health fined Sharp Memorial Hospital $100,000 for an incident in which surgeons mistakenly removed a 53-year-old man’s healthy kidney. It also levied a $50,000 penalty against Alvarado Hospital for a case involving an elderly patient who fell out of bed, hit her head on the floor and died.
Sharp and Alvarado were among nine hospitals in the state that were fined a total of $775,000 on Thursday for errors that put patients in “immediate jeopardy” of serious injury or death.
Sharp HealthCare officials said they regret the surgical mistake. Dan Gross, the network’s executive vice president of hospital operations, said the patient received an apology quickly after the mix-up was discovered.
“More than anything, we have made a commitment to (him) to do everything in our power to have this not happen again,” Gross said.




photo
Paul Kibbett / courtesy photo

The patient, Paul Kibbett of Escondido, sued Sharp and several doctors for unspecified damages on Aug. 7, 2012, alleging medical negligence and battery.
His attorney, Virginia Nelson, said the problems started on Jan. 3, 2012, at Palomar Medical Center, where Kibbett, who suffers from cerebral palsy, had a CT scan that detected a cancerous mass in his right kidney.
There was an initial scan mix-up that identified the left kidney as needing removal, but that mistake was quickly corrected, according to the state’s report on the Kibbett incident. But by the time Kibbett underwent surgery at Sharp Memorial on Jan. 19, 2012, his medical records again listed the left kidney as requiring removal.
Though Sharp Memorial policy said physicians should have the patient’s X-rays or CT scans present in the operating room before surgery begins, the lead surgeon in this procedure, according to the state, “forgot the necessary login information needed to access the images remotely.”
That surgeon, whom Kibbett identified in his lawsuit as Dr. Evan Vapnek, decided to remove the left kidney without the radiological verification, according to the state report.
Dr. Geoffrey Stiles, Sharp Memorial’s chief medical officer, said it wasn’t possible to reattach the healthy kidney. And it was still necessary to remove the cancerous right kidney. Stiles said the patient doesn’t qualify for a transplanted kidney from a donor, meaning that he will need ongoing dialysis to survive.
Kibbett’s lawsuit names Sharp, Vapnek and doctors Thomas Jones and James Roberts as defendants. Two other parties were initially listed, but have settled or are in the process of being dismissed from the suit, Nelson said.
Nelson also said Kibbett lives with his sister and legal guardian, Karen Brousseau, who declined to discuss the case Thursday.
“He and his family will live with the awful consequences of this for the rest of his life,” Nelson said.
Vapnek said in an email that Sharp provided to U-T San Diego this week: “Helping patients heal is my life’s work, and I have never felt such personal anguish as I did when we discovered the wrong kidney had been removed. I have expressed my sincere regret to the patient and the family over this tragic incident, and Sharp has been diligently providing the additional care required. With the assistance of my colleagues and the staff at Sharp, I have rededicated my practice to make every effort possible to prevent such an error from happening again.”
Gross, the Sharp operations executive, said Vapnek’s record is otherwise unblemished, adding that he has retained his operating privileges at Sharp Memorial.
Jones and Roberts didn’t respond Thursday evening to a request for comment.
The botched surgery occurred one month after a wrong-side surgery at the same hospital nearly cost a man his only healthy testicle. In August, the state fined Sharp Memorial $75,000 after a surgeon made an incision on the right side of the patient’s groin before realizing that it was the patient’s left testicle that was scheduled for removal.
In that case, state inspectors said the surgical team involved didn’t follow the hospital’s extensive procedures for properly identifying the correct side.
Stiles, the chief medical officer at Sharp Memorial, said the two cases were similar in that they involved confusion of left and right sides but differed in the exact mechanisms that allowed them to happen.
He also said additional training occurred after the testicle case — and continues to this day. No additional wrong-side surgeries have occurred since the Kibbett kidney incident, he said.
And Stiles said Sharp has strengthened enforcement of its operating procedures in the wake of the kidney mistake, making X-rays a strict requirement for certain types of surgery where there is a potential for confusion.
In the Alvarado Hospital incident, state investigators said an elderly woman who had fallen at a local skilled-nursing facility was admitted to Alvarado in early 2012. She was being monitored when she fell from her hospital bed and suffered a head wound that caused her to die the next day, they said in their report.
The state found that a nurse turned off a special alarm designed to warn hospital personnel if a fall-prone patient was trying to get out of bed. That action was taken “because the patient wanted to sit on the edge of the bed,” an activity that would frequently set off the sensitive alarm, according to the state.
Alvarado didn’t release a statement Thursday about the incident, though its report to the state said the hospital took steps to make sure its employees followed fall-risk policies and added a portable “personal alarm” device to make falls less likely.
copied from the UT...............

Oct 25, 2013

The Wrong Kidney Removed and Life in the OR at Sharp Memorial San Diego

Cut time:  rushing......why isn't the patient in the room?

Did we do the time out?  Did everyone listen?  Did the surgeon listen?

The Wrong Kidney Removed and Life in the OR at Sharp Memorial San Diego

Seriously, life at Memorial, perhaps the Sharp OR will now shift their focus to patient safety instead of rushing for the surgeon's convenience.

copied from nbcsandiego.com..............

2 San Diego Hospitals Fined by California Dept. of Public Health

One facility was fined for failing to prevent a patient's fatal fall, while the other was fined for removing the wrong kidney from a patient

By Monica Garske
|  Thursday, Oct 24, 2013  |  Updated 9:21 PM PDT
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2 San Diego Hospitals Slapped with Fines
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Two San Diego-area hospitals were fined by the California Department of Public Health (CDPH) on Thursday after investigations found that one facility failed to prevent a patient's fatal fall, while staff at the other facility removed the wrong kidney from a patient during surgery.
According to the CDPH, penalties were issued to Alvarado Hospital Medical Center and Sharp Memorial Hospital in San Diego County because the facilities’ non-compliance with licensing requirements likely caused serious injury or death to patients.
According to a report filed by the CDPH, Alvarado Hospital Medical Center was given a $50,000 penalty for failure to ensure the health and safety of a patient when the hospital did not follow established policies and procedures regarding fall prevention.
The report says a registered nurse turned off a bed alarm for a high fall-risk patient and the patient fell out of her bed, hit her head and suffered a bleed into her brain tissue stemming from the fall. The patient died the next day.
An investigation into the incident was launched in February 2012. In the end, the investigation determined that failure to prevent the fall resulted in the patient’s death, according to the documents.
The CDPH said this is Alvarado Hospital Medical Center’s first administrative penalty.
Meanwhile, Sharp Memorial Hospital, San Diego, was issued $100,000 penalty because the hospital failed to ensure the health and safety of a patient when it didn’t follow surgical policies and procedures.
A report filed by the CDPH says medical staff incorrectly removed the left kidney of a patient during a surgical procedure. The 53-year-old patient had a suspected cancerous mass in his right kidney, but staffers failed to correctly identify the surgical site on the day of the operation, ultimately removing the wrong kidney.
“The failed surgical team failed to have any of the relevant images of the kidney(s) available and displayed during any part of the surgical procedure,” the report states.
The patient survived, but the hospital is still being fined for failure to prevent the deficiencies, which caused serious injury to the patient. The CDPH says this is the hospital's fourth administrative penalty.
The local hospitals are just two out of nine California medical facilities fined by the CDPH on Thursday.
Other facilities include: St. Jude Medical Center, Fullerton, in Orange County; Antelope Valley Hospital in Los Angeles County; Community Regional Medical Center in Fresno County; Community Regional Medical Center in Fresno; LAC/Harbor-UCLA Medical Center, Torrance, in Los Angeles County; Mercy Medical Center in Merced County; Mission Hospital Regional Medical Center, Mission Viejo, in Orange County; Santa Clara Valley Medical Center, San Jose, in Santa Clara County.
The CDPH says administrative penalties are issued under authority granted by Health and Safety Code section 1280.1. A penalty carries a fine of $50,000 for the first violation, $75,00 for the second and $100,00 for the third or subsequent violation.


Source: http://www.nbcsandiego.com/news/local/2-San-Diego-Hospitals-Fined-by-California-Dept-of-Public-Health-229202551.html#ixzz2ikTYaNSQ