Marin General Hospital Fined $50,000 for Leaving Sponge in Patient
For the second time in two years, state health officials have fined Marin General Hospital for an error determined to be likely to cause serious injury or death to a patient. Last year, the California Department of Public Health fined the Greenbrae hospital $25,000 for failing to remove a sponge from a patient following an emergency abdominal surgery conducted in 2007. The second error, for which MGH is being fined $50,000, occurred on September 18, 2009, during an elective Caesarean section surgery, the Marin Independent Journal reported yesterday.
The September 2009 C-section surgery in which a surgical sponge was left in a patient was apparently complicated by the patient losing two pints of blood. Special bags were employed to account for surgical sponges and prevent them from being left behind. However, according to an incident report, the staff thought the last sponge was on the operative field and not in the patient's body, and there was some confusion about the location of the last sponge.
An obstetrics technician and registered nurse who failed to follow policy were disciplined. A surgical urologist and physician leader at Marin General Hospital said, "We have a zero tolerance policy for this sort of a problem. There are no exceptions based on the complexity of the operation, period."
Doctors suspected a problem three days after the surgery, when the patient showed symptoms of an intestinal obstruction. A CT scan reportedlly "suggested the possibility of an intra-abdominal foreign body." Two days later, a follow-up CT scan revealed the foreign body. The surgery was performed that same day to remove the sponge. The patient was discharged two days later. The Marin Independent Journal also reported that the incident report revealed the patient's medical record when she was discharged did not mention the surgical sponge left in the patient or the second surgery performed to remove it. The incident report said that according to the hospital's own policies, the attending physician is required to write a complete discharge summary including all procedures performed, treatment rendered and anything else of significance.
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