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Sponge left in patient ends in fine for Kaiser
By Shauntel Lowe/Times-Herald, Vallejo
The Kaiser Foundation Rehabilitation Center in Vallejo has been fined $25,000 after staff members last year left a sponge inside a surgical patient.
The mishap necessitated a second surgery for the patient and the removal of a portion of her bowel.
The center on Sereno Drive was one of 12 hospitals in the state assessed penalties by the California Department of Public Health, it was announced Thursday.
Five of the named hospitals, including Kaiser, were fined for leaving foreign objects inside surgical patients. In one case, a man only discovered a portion of a stapler had been left in his intestine, after a colectomy, once he heard a metallic clank in the toilet during a bowel movement.
Kaiser officials said they have instituted additional staff training and will pay the fine.
"We have apologized to our patient and expressed our deep regret that we did not follow our policies and procedures completely in this case," said Kaiser Permanente Acting Area Manager for Napa and Solano Karen Grisnak in an e-mailed statement.
Hospital policy requires all surgical objects, like sponges and needles, to be accounted for before a patient's open cavity is closed. However, according to a case report, Kaiser staff counted the instruments as the surgeon was closing up the patient.
In the November 2008 incident, a woman only identified in a state report as "Patient 9" underwent surgery to have a small bowel obstruction removed.
Three weeks later, Patient 9 saw her primary care doctor because she was constipated and otherwise not feeling well, according to the report.
An X-ray of the woman's abdomen followed by a second surgery revealed a foreign object, which turned out to be a sponge "anchored to the kidney," the report states.
A small portion of Patient 9's bowel was infected because of the sponge and removed, the report states.
Kaiser officials would not say whether Patient 9 is suing the hospital. A search of Solano County court records since November 2008 did not turn up any apparent cases related to this incident.
Officials from several federal health agencies said there is no specific data tracking how many sponges are left inside patients each year, and little comprehensive data on how many foreign objects overall are left behind.
One official, however, did say that the incidence of sponges being left behind is likely more rare than people imagine.
A 2003 study in The New England Journal of Medicine titled "Risk Factors for Retained Instruments and Sponges after Surgery" cited emergencies, higher body-mass index and unplanned changes in procedure as factors that significantly increased the risk of objects being left behind.
Leaving the sponge inside of Kaiser's Patient 9 is considered an "immediate jeopardy" violation of state standards. State health officials in a conference call Thursday said not all hospitals are assessed penalties for this category of violation, but they could not say how officials decide who does and does not get fined.
To view the report on Kaiser's violation, as well as those of the other hospitals, visit www.cdph.ca.gov, click the "Certificates & Licenses" tab at the top and select the "Health Care Facilities" link.