State fines Modesto's Memorial Medical Center $125,000 over patient safety

02/06/2013 11:05 AM

06/26/2013 2:31 PM

Memorial Medical Center of Modesto was ordered to pay $125,000 in administrative penalties to the state for violations that jeopardized patients. One incident resulted in the death of a 65-year-old man who had gone to the hospital for routine kidney stone surgery, an investigation found.

Memorial was among seven hospitals in California assessed a total of $775,000 in penalties by the California Department of Public Health, which announced the fines Wednesday. The penalties against Memorial were the largest state fines assessed to a hospital in Stanislaus County since 2011, when Emanuel Medical Center of Turlock was fined $125,000 for two incidents.

Memorial was fined $50,000 for a December 2011 incident in which the 65-year-old man stopped breathing for 17 minutes after outpatient laser surgery to remove kidney stones.

According to a state investigation, the anesthesiologist tried to restore the patient's breathing but did not call a "code blue" to summon an emergency team to resuscitate the man.

The delays resulted in severe brain injury, investigators concluded. The patient was placed on a ventilator and died 11 days later.

A second incident in May resulted in a $75,000 fine against the 423-bed Memorial after a surgery was performed on the wrong patient. Investigators found that staff mixed up the ultrasound results of a patient with a blood clot in the leg with a woman who had no blood clot.

Fearing the supposed clot could travel to heart and lungs, doctors implanted a filter inside a large vein of the patient with no blood clot. State officials did not release the names of the patients.

Memorial issued a statement Wednesday on the administrative penalties.

"It is unfortunate that these adverse events occurred at our medical center," said Daryn Kumar, the hospital's chief executive officer. "Our employees and physicians are caring professionals committed to nurturing a culture of safety and quality. We want the best outcomes for every one of our patients."

Hospital staff notified the patient and respective family members in a timely manner and reported the events to the state, the hospital said.

Memorial officials investigated both incidents, and a team of doctors, nurses and other staff developed ways to prevent such "adverse events," the statement said.

Investigative reports

State officials released investigative reports on the two incidents.

The 2011 surgery, using a scope and laser to break down kidney stones in the patient, was done under general anesthesia without complications.

When the breathing tube was removed, however, the patient started thrashing his arms, prompting nurses to hold the man on a gurney while the anesthesiologist delivered propofol to calm him. (Pop superstar Michael Jackson is believed to have died from a lethal dose of propofol given by his physician.)

According to a report on the Memorial incident, the anesthesiologist noticed that the man stopped breathing about 60 seconds after administering the drug. The doctor attempted to insert an airway tube and tried other ways to revive him.

The patient did not start drawing oxygen again until he was put on a breathing device and chest compressions were performed.

The anesthesiologist told an investigator, "I zoned out," when asked why he didn't call a code blue, the report says.

Ultrasounds mixed up

In regard to the May incident, state officials blamed the hospital for not having a safety process to prevent ultrasound results from being mixed up.

Hospital staff notified the woman about the mistake, and arrangements were made to remove the implanted filter, a report says.

Investigators found that the other patient, who had a blood clot, had been treated appropriately and sent home.

Among the hundreds of patients treated at Memorial each day, the two patients had come in with similar pain and swelling in the right leg.

Memorial said the state has accepted its correction plans, which include stronger policies for calling a code blue and analyzing those events.

To prevent mistakes with test results, physicians are given fewer exams to read at one time and worksheets have patient information stickers on every page.

The state agency issues the administrative penalties every three months to improve safety for patients, said Debby Rogers, deputy director of the department's Center for Health Care Quality.

"Information on the incidents that led to penalties will be used to determine how these violations can be decreased and eliminated over time," Rogers said.

Bee staff writer Ken Carlson can be reached at or (209) 578-2321.

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