The California Department of Public Health cited Marian Regional Medical Center on Dec. 17 for a surgical operation in 2014 that left a medical device inside a woman’s abdomen.
The fine comes following a report that detailed an investigation into a bungled hysterectomy surgery. According to the report, a 54-year-old woman was admitted to Marian in April 2014 for surgery to remove noncancerous growths on her uterus.
During the robotics-assisted operation, the report states the surgeon used a Toomey syringe bulb—a two-and-a-half inch bulb at the end a syringe—to prevent air from getting inside the woman’s abdomen. The syringe was inserted in the woman’s vagina to reach her abdomen, according to the report.
All instruments were twice accounted for at the end of the surgery, the report notes, but somehow the bulb was forgotten.
The patient reported abdominal bruising and bleeding in several follow-up visits to the doctor, the report notes, but was told by the doctor that it was normal.
Six weeks later, the doctor discovered the device following an inspection. Corrective surgery was performed following the discovery.
The report found that there was a miscommunication between the nurse and the doctor at the time of the surgery. A nurse and scrub technician told state officials that items introduced during surgical procedures were announced out loud beforehand and then written on a whiteboard.
However, the report notes that both the nurse and technician admitted to not hearing the doctor announce the addition of a bulb.
The surgeon admitted to not doing a “methodical wound sweep and vaginal exploration” that hospital policy required, the report also stated.
A review of the incident found that several policies were violated, such as failing to account for and inspect all instruments and devices, and failing to conduct a proper wound sweep. For that, the hospital was fined $28,500.
Megan Maloney, a spokeswoman for Marian, said in a statement that this was an isolated incident that the hospital takes very seriously.
“We conducted a thorough investigation of this matter and have worked closely with the medical staff, patient care staff, and hospital leadership to ensure that an occurrence like this doesn’t happen again,” Maloney wrote in an emailed statement to the Sun. “Procedural changes put in place have been successful, and no other patient has experienced this complication.”
This article appears in Jan 12-19, 2017.