Sister Hospital of Sharp Grossmont Fined by State for Medical Mistake

Sharp Grossmont’s sister hospital in San Diego was one of five in San Diego County to receive administrative penalties Thursday from a state oversight agency.

The state Department of Public Health said it fined Sharp Memorial on Frost Street $25,000 after it “failed to ensure the health and safety of a patient when it failed to accurately administer a prescribed medication.”

But as The San Diego Union-Tribune noted in a report Friday, Scripps Memorial Hospital La Jolla was fined a total of $175,000 this week “for errors that caused or could cause serious injury or death to patients.”

Counting two fines in 2011, Scripps Memorial has received six fines since the state Department of Public Health began issuing them in 2007—the most in San Diego County.

Sharp Grossmont Hospital of La Mesa received no penalties in 2011, but was fined in 2008 and 2010, according to state records.

One mistake led to the death of a 45-year-old man brought to the emergency room early one morning in March 2008. Another led to a 93-year-old emergency room patient being operated on the wrong side of his brain.

“Those issues have all been addressed and procedures were put in place immediately to prevent such events from happening again,” Bruce Hartman, a hospital spokesman, said Friday. 

“Sharp Grossmont always takes our patients’ health and safety to heart, and we remain vigilant with continuous quality improvement initiatives.”

In 2008, Sharp Grossmont was fined $25,000 after the hospital “failed to activate a stationary ventilator during a transfer of the patient from a transport ventilator, resulting in the patient’s death.”

The state found that a respiratory technician had taken the emergency room ventilator to another lab, where the ventilator had been left in “standby” mode.

“[The technician] stated that the standby mode is much like having a car in idle; it’s ready to go, but you need to push the pedal to get it moving,” the state found in a report (attached).

The standby button needs to be pushed again in order to activate the ventilator. Another technician working the morning of March 21, 2008, “could not recall if he had taken the ventilator out of standby mode after transferring Patient A.

“[Therapist] “W” stated that there is no written policy for respiratory staff to provide a verbal report to the nursing staff regarding the care and function of the
ventilator.”

A half-hour later, after the mistake was noticed and CPR commenced, “Patient A was pronounced dead at 5:34 a.m.,” the state said.

In 2010, the state says, Sharp Grossmont was cited for opening the skull of a 93-year-old man on the right side—when they were supposed to operate on the left.

In that January 2009 incident (attached), the state said: “The entire surgical team all agreed to the procedure and then began the surgery, but on the wrong (right) side of the head. …The surgical team realized the error when they were unable to find bleeding in the right side of the brain.”

This led to “Patient R” having to endure extended time in surgery under general anesthesia while the surgical team performed surgery on the left side, the state said.

A surgeon had marked the wrong side of the skull after the elderly man had been moved from the emergency room to the intensive care unit, the state found.

“The hospital’s … Universal Protocol for Surgical and Invasive Procedures was reviewed” several weeks later and noted  “that the marking of the patient
will be performed ‘before the patient is moved to the location where the procedure will be performed.’ This aspect of the [protocols] was not followed.”

The state listed seven corrective measures taken, including: “All Operating Room staff were educated on the Universal Protocol policy and Time Out procedure, including the requirement for ALL staff and physicians to pause and actively participate in the Time Out, each actively participating in verifying the correct patient, correct procedure, correct side, correct site at morning report.”