$100K Fine Against Mission Hospital for Surgical Mistake

Mission Hospital has been ordered to pay the state $100,000 after a surgeon mistakenly left a tiny metal screw cap inside a woman following surgery.

This is the fourth recent fine administered to the hospital by the California Department of Public Health. Such fines are only leveled when a mistake is deemed life-threatening, said Pam Fossdick, acting deputy director of CDPH's Center for Health Care Quality.

The fine stems from a back surgery from early 2010 involving a 71-yer-old woman. The exact date of the surgery has been redacted to protect the patient's identity.

After staff X-rayed the woman to make sure the surgery was successful, they found the cap to an 8x5mm metal screw still inside her.

Both the surgeon and the woman's family elected to have a second surgery, a choice that put her life in jeopardy, according to the state report.

The report says the surgery department "did not notify their management staff and did not file an incident report" following the mistake. The incident was later discovered during a review of unplanned surgeries. The CDPH was notified by the hospital on April 6, 2010.

Hospital policy did not require the screw caps to be counted, but the surgeon did count the caps per his own personal practice, according to the report. But somehow the surgeon counted all caps as being removed. "It remains unknown how one of the screw caps was retained," according to the state report.

How could the removal of the screw cap have led to death, as required for the state mandated penalty? According to the report, the second surgery put the patient at risk of anesthesia and possible infection from an otherwise unnecessary surgery.

Foreign objects left after surgery are the second-most-common reason for hospitals to receive fines from the state, Fossdick said. The most common mistakes are medication errors, she said.

Only hospitals that self-reported potentially deadly incidences to the state were included in the CDHP's report.

This incident is the fourth reported by Mission Hospital to the state since July 2009. The first incident involved a woman who had just given birth to triplets July 24, 2009. In that incident, a nurse accidentally gave morphine to a newborn. The morphine was intended for the mother.