The hospital, owned by Dignity Health, was fined $28,500 for a 2014 surgery in which a syringe bulb was left in a 54-year-old woman during a surgery to remove tumors on her uterus. The hospital failed to follow proper procedure after the surgery to check the wound site and ensure no items had been left inside.
It was the first time Marian 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. It was also the only local hospital to be cited this week.
In 2016, Twin Cities Community Hospital in Templeton was similarly fined, after the hospital performed a surgery on the wrong finger of a patient.
Megan Maloney, director of marketing and communications for Marian Regional Medical Center, said the hospital has since implemented procedural changes to prevent other patients from experiencing a similar incident.
“Patient care and safety are always our highest priority and we take this matter very seriously,” she said in a statement. “This was an isolated incident which occurred in 2014. Since then, procedural changes put in place have been successful and no other patient has experienced this complication. We conducted a thorough investigation of this matter and have worked closely with the medical staff, patient care staff, and hospital leadership, to ensure that an occurrence like this does not happen again. Our hospital is committed to excellence in quality and patient safety.”
The state instituted the penalty program to police hospitals and help avoid practices that harm patients. 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.
The state’s report does not name the surgeon or the patient, but it details the state’s investigation and findings.
According to the report, the woman was scheduled to undergo surgery in April 2014 to remove noncancerous growths that had developed on her uterus. There was also a possibility the surgeon would perform a hysterectomy entirely removing her uterus and ovaries, the report states.
During the procedure, the surgeon placed a “Toomey syringe bulb” (TSB) — a removable bulb on the end of a syringe, normally used for removing liquids — inside the woman’s vagina to maintain air pressure in the cavity while the surgeon operated.
Standard procedure requires the surgeon to announce when any item was added to the patient. That item would then be written down on a whiteboard and checked once the surgery was completed to ensure it had been removed.
According to the report, neither the the nurse nor the scrub technician present recalled hearing the surgeon announce the bulb. The item was not added to the whiteboard and was never included in the nursing record for the day.
Operating procedure also requires the surgeon to perform a methodical wound sweep and vaginal exploration after completing this specific surgery, to ensure that no items have been left behind. A surgical count of all the implements used during the procedure is also required.
The surgeon told investigators that she did not perform a wound sweep or exploration.
The patient returned to the surgeon for a follow-up appointment two weeks later, complaining of bruising and pain in her abdomen, plus bleeding. According to the report, the surgeon told her it was normal, and did not perform a pelvic examination to check.
When the patient returned for another follow-up appointment six weeks after the procedure, she once again complained of pain and said the bleeding had intensified.
After an examination, the surgeon said she thought she saw something plastic in the woman, but was unable to remove it because the patient was in too much pain. The woman was admitted to a different outpatient surgical center, where the bulb was removed in a second surgery.
The report concluded:
“These failures resulted in the retention of a TSB in Patient 1 and the necessity for a second surgical procedure under general anesthesia to remove the retained TSB. This is a deficiency that has caused or is likely to cause serious injury or death to the patient, and therefore constitutes an immediate jeopardy within the meaning of the Health and Safety Code ”
Marian has since reviewed its procedures for preventing leaving surgical items in patients — in particular the requirement to perform a methodical wound sweep — and met with the patient to apologize and review actions taken to prevent it happening again. According to the report, all associated costs to the patient were covered by the facility.
The hospital’s director of surgical services will also conduct a random audit of 10 cases per month to ensure items used in surgeries are correctly listed on the count board, as well as random audits of 10 gynecology cases per month to ensure all surgeons are conducting methodical wound sweeps.
The other hospitals cited by the state this week are: Anaheim Regional Medical Center, South Coast Global Medical Center and St. Joseph Hospital in Orange County; College Hospital (fined twice), Garfield Medical Center, Keck Hospital of USC, Los Angeles Community Hospital, Pacifica Hospital of the Valley, Southern California Hospital at Hollywood, St. Mary Medical Center and Valley Presbyterian Hospital in Los Angeles County; and Scripps Mercy Hospital and Tri-City Medical Center in San Diego County.
The 15 fines totaled $913,550.