Woman in surgery suffered face and chest burns in 2010
The California Department of Public Health announced Thursday that Sutter Coast Hospital is being fined $10,000 in connection with a 2010 oxygen mask fire that left a patient with second-degree burns to the face and chest.
Sutter Coast Hospital was one of 10 hospitals to receive administrative penalties from the department for noncompliance with licensing requirements that have caused or were likely to cause serious injury or death to patients, according to a CDPH press release.
A CDPH report said a Sutter Coat patient was undergoing surgery to remove skin cancer from the right side of the forehead when the surgery drapes around the patient’s head and oxygen mask on the patient’s face caught fire. The fire was started by a high flow of oxygen through the face mask and an electrical cautery device used to coagulate wound tissue on the forehead, the report said.
Operating room staff removed the surgery drapes and oxygen mask and extinguished the fire with water, the report said. The oxygen mask was described as an open style with five openings and 14 feet of tubing.
The patient, who was not identified, stated that she was in intensive care for two days after the surgery, the report said. She said she had trouble with her mouth and she did not want to leave her house because of the way she looked after the incident.
Sutter Coast Hospital immediately self-reported the incident and has cooperated with the state’s investigation, according to hospital spokeswoman Beth Liles. A civil suit was not filed in connection with the incident, Liles said.
“We initiated a very aggressive and thorough review process following the event,” Liles said. “The hospital developed and submitted a corrective action plan that improves training, documentation, process and accountability to prevent an event like this from recurring.”
The hospital has a new policy entitled Fire Prevention and Management in an Oxygen Enriched Atmosphere, according to CDPH’s report. Under this policy, surgical staff must use moistened towels, sponges and drapes for all head and neck patients. The policy also requires surgical staff to stop the use of oxygen one minute before using the cautery device.
The CDPH announced this week that it had issued $785,000 in penalties at hospitals in Del Norte, Alameda, Los Angeles, Marin, Orange, San Diego, San Francisco and Tulare counties. Violations ranged from objects being left inside patients to a doctor at a San Diego hospital removing the wrong kidney from an elderly patient.
Administrative penalties carry a fine of $50,000 for the first violation, $75,000 for the second violation and $100,000 for the third or subsequent violation, according to a department press release. However, the CDPH has the authority to reduce the amount of a penalty issued to a rural hospital.
“The Health and Safety Code allows us when enforcing a penalty against a small and rural hospital to consider special circumstances,” said Debby Rogers, deputy director for the Center of Health Care Quality.