The Department of Public Health announced that they fined nine California hospitals for severe medical errors–some of which killed or seriously injured patients last year, as reported by Molly Hennessy-Fiske at the LA Times.
The list of errors is gruesome, and is a reminder of why these are called “never events.” They aren’t “sometimes events” or “stuff happens” events, but errors where there should be systems and fail-safes in place to ensure they never happen. We need more reporting and scrutiny on these errors, and more accountability. We have supported legislation to have the state Medi-Cal program join Medicare in not paying for such care, along with the corrective actions like the fines announced today.
We also need to encourage the systems that ensure that these problems don’t happen. One example stood out because the solution was clear:
In Riverside, Parkview Community Hospital was fined after a surgeon with hospital privileges in July removed the wrong kidney from a Spanish-speaking patient with a kidney tumor. Investigators found out the patient was not provided an interpreter before he consented to the surgery. Francisco Torres, 72, lost his one healthy kidney, was placed on dialysis and sued the surgeon and hospital for medical negligence.
While this is a severe example, it’s problems like this why we and many of our allies have advocated for language access standards in both public and private health coverage, and why we have been so active with our Video Medical Interpretation project, in trying to ensure that language is not a barrier to quality, appropriate care.