For the second time Emanuel Medical Center in Turlock has been issued an administrative penalty after the California Department of Public Health concluded the hospital had not fully complied with health and safety standards.
The hospital was fined $75,000 for failing “to ensure the health and safety of a patient when it did not follow its surgical policies and procedures,” the CDPH stated in their news release.
The fine stems from an incident in 2010 in which a guidewire was mistakenly left inside a patient. Guidewires are used to guide a catheter into place and is then removed.
EMC President and Chief Executive Officer John Sigsbury said a guidewire being left inside a patient “was a very rare occurrence” and one that he had not seen in his 32-year career.
“I have great confidence we will not see anything like this again,” Sigsbury said.
According to the CDPH’s investigation into the matter, a guidewire was left inside a patient’s right femoral vein. The patient was originally admitted to the hospital’s emergency department with pneumonia in both lungs and sepsis, and a catheter was put in as part of the treatment, according to the CDPH.
“The hospital staff performed very courageous acts that saved this patient’s life,” Sigsbury said. “It’s just unfortunate that this rare event occurred.”
The CDPH report states that a chest x-ray of the patient showed the guidewire “visible over the large vein leading into the heart (indicating the guidewire had traveled from the groin into the heart).”
The discovery of the guidewire was made by EMC staff and was retrieved the following day without any complications to the patient. EMC was also the party to report the incident to the CDPH, Sigsbury said.
During subsequent interviews with hospital administrators, the CDPH was told the hospital’s emergency department “had no policy or procedure covering how to account for guidewires in placement of central line catheters.”
Additionally, the CDPH spoke with the doctor assigned to the patient and the physician said he “must have been distracted and accidentally let go of the guidewire sometime during the process.”
EMC has created a policy to deal with guidewires that in part, require the physician to verbally announce the removal of a guidewire.
This was the second time EMC has been fined by the CDPH. In June the hospital was fined $50,000 for failing to follow the standard procedure of preforming an electrocardiogram before dispensing Droperidol, a medication that has been shown to disrupt heart rhythms. The CDPH’s survey of the hospital found that one doctor had administered the drug to five patients without the required EKG test. The hospital decided to no longer dispense Droperidol.
In all, the CDPH fined 12 hospitals for noncompliance issues. The CDPH started issuing fines in 2007 and has since collected $4.6 million, according to Pam Dickfoss, the acting deputy director of CDPH’s Center for Health Care Quality. The fines are supposed to go into special accounts that can be used for purposes of raising awareness about the specific violations. In part, this is one reason EMC plans to appeal the penalty, Sigsbury said, because the occurrence is so rare it doesn’t really need an awareness campaign.
The only other hospital in the area to be singled out for a fine was the Stanislaus Surgical Hospital. According to the CDPH, the hospital did not adequately verify the surgical spot and made an incision into the wrong leg before correcting the mistake. The hospital was fined $50,000.
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