'Never events' in California hospitals on the rise

While many California hospitals like San Francisco General have been working hard in recent years to bring an end to "never events"--events that are never supposed to occur, such as leaving medical equipment inside a patient after surgery--the number of cases continues to rise at an astonishing rate. Fourteen percent of all preventable errors reported since 2008 have involved objects being recovered in patients after surgery, according to the San Francisco Chronicle--nearly 200 in the latest fiscal year, and 150 the year before. 

In the case of San Francisco General, one incident was all it took for administrators to make drastic changes in a hurry. After a small piece of sponge was found to have been left inside a cancer patient three months after her 2008 surgery, the hospital was fined $25,000. Since then, the hospital has moved away from using pieces of sponge as small as the one found in the patient (4-by-8 inches), and also has implemented a post-surgical x-ray procedure to determine if any instruments are not accounted for. All pieces of sponge used now also contain a "special strip" for easy identification via the x-ray. 

Since the one incident, San Francisco has been error free in that regard. For other hospitals, though, such drastic measures might not be so easy. That's why the state plans on using $800,000 of the $3 million in penalties collected since 2007 to research what hospitals need to do to lower their never-event rates. 

"We really want to drive change," Kathleen Billingsley, deputy director for the California Department of Public Health's Center for Health Care Quality, told the Chronicle. "Penalties are one way of driving this change." 

Because a statute of limitations currently does not exist in such cases, meaning a hospital that left a piece of equipment in a patient this year could be fined three or four years from now for such a mishap, one lawyer representing hospitals believes that the state's actions are tantamount to the hospitals being "terrorized." 

"You can get a letter a year later saying we're fining you $50,000 for a retained foreign object you reported a earlier," Mark Kadzielski told the Chronicle. "It's unfair and unsettling to hospitals."

For more information:
- read this San Francisco Chronicle article
- check out this California Healthline piece