Twin Cities was fined $50,000 for a 2013 surgery on the wrong finger of a patient, which required the patient to need a second surgery, the state announced Thursday. The hospital failed to follow proper procedures to avoid what is called a “wrong site” surgical error.
It was the first time Twin Cities has been fined since the state began issuing penalties to hospitals in 2007 for avoidable, “immediate jeopardy” mistakes that cause or are likely to cause death or serious injury.
The state’s report does not name the surgeon or the patient, but details the state’s investigation and its findings.
According to the report, the patient saw the physician in the office three times in late summer and early fall of 2013 and was diagnosed with tendon damage to the left ring finger that prevented her from being able to straighten the finger.
The patient went to Twin Cities on Nov. 5, 2013, for the surgery. The physician had faxed over an appointment form that said the surgery would be done on the left ring finger, and that information was included on the hospital’s surgery schedule. However, the physician also sent a surgical order to the hospital on the day of surgery that did not specify which finger on the left hand was being operated on. The physician also sent a form for the hospital staff to have the patient sign a consent form, and also a form instructing the staff to verify the surgical site. Neither form clarified which finger would be treated.
Under proper procedure, the surgeon would mark the surgery site before the procedure. Before the surgery starts, the entire surgical team is required in what is called a “time out” to verbally confirm that they have the correct patient, correct surgical site, agree on the procedure and other details.
The physician told investigators that before the surgery, he marked the patient’s left hand but not the actual finger. During the “time out,” the surgical team did not clarify the correct finger that would be operated on, investigators found.
The report concludes, “the facility’s failure to ensure staff followed their policy and procedure is a deficient practice that has caused or is likely to cause serious injury or death to the patient and constitutes an immediate jeopardy” under state law.
On Thursday, Twin Cities spokesman Ron Yukelson said, “The physician who performed the 2013 surgery subject to penalty no longer practices at our hospital. At the time, we conducted a thorough internal review and reinforced our surgical policies and procedures.
“Providing safe, high-quality patient care is our primary focus.”
The state Department of Public Health instituted its penalty program “to both police hospitals and help them avoid practices that harm patients,” according to a news release. The program requires hospitals to report any immediate jeopardy errors to the state, and to file a plan of correction after a CDPH investigation is completed.
Twin Cities filed a correction plan that included implementing a new pre-surgery “time-out” form for the surgical team to use, implemented a “speak up” policy to create a safe environment for employees to intervene to protect patient safety without fear of retaliation, counseled the employees who failed to follow the proper policy, and stepped up auditing of patient charts to ensure procedures are followed.
The seven other hospitals penalized on Thursday were: Community Regional Medical Center in Fresno, Kaiser Foundation Hospital in Fontana, Kaiser Foundation Hospital in Santa Rosa, San Joaquin General Hospital in French Camp, Sonoma Valley Hospital in Sonoma, Ventura County Medical Center, and Vibra Hospital of San Diego. Total fines were $483,650.