on the cover / By Carrie Peyton Dahlberg

Operator Error

Redwood Memorial and St. Joseph have both reported major surgical mistakes –- now what?

(Dec. 29, 2011)  Rumors are swirling about the St. Joseph Health System, a presence in Humboldt County since the Sisters of St. Joseph of Orange began treating flu patients here during the 1918 epidemic.

While much remains unconfirmed, St. Joseph Hospital in Eureka and its sister facility, Redwood Memorial Hospital in Fortuna, both have made dramatic medical blunders within the past 12 months, and St. Joseph’s chief medical officer is leaving or has left.

GALLERY >

Dr. Scott Sageman is stepping down from the organization’s top medical job and “transitioning back to direct patient care,”  Laurie Watson-Stone, vice president for ancillary and support services, said last week. The hospital first scheduled then canceled an interview with the Journal to speak about that and other issues. It initially declined interviews and said it would consider responding only to written questions. Later, spokeswoman Leslie Broomall softened that stance somewhat and accepted a few questions over the phone, but she did not provide any answers in time for the Journal‘s deadline.

The hospital is required to communicate with regulators, and a picture emerges from California Department of Public Health records of serious surgical issues, including surgery on the wrong body part in January and leaving equipment in a patient after surgery at least once in June, and possibly a different time in July.

Such errors are both utterly avoidable and utterly human. Because they have potentially devastating consequences, doctors have grappled for years with preventive steps, backup plans and checklists to try to avoid them. Among those weighing in has been noted surgeon and Harvard professor Dr. Atul Gawande, whose book “The Checklist Manifesto: How to Get Things Right,” was published in 2009.

In at least two of the recent errors at St. Joseph system facilities, the checklist systems failed because they were not properly attended to, according to deficiency reports from the state of California.

And these weren’t the first time such problems have cropped up. This month, after prolonged wrangling, attorneys for the state and the hospital system reached a $16,500 settlement over a different piece of equipment, left behind in a different patient’s body, at Redwood Memorial in 2008. The state imposed a $25,000 fine for that episode in 2009, but hospital officials negotiated it down to about two-thirds of the original amount. That settlement was reached on Dec. 16 of this year, said Ralph Montano, a spokesman for the public health department.

On top of all that, the state’s Radiation Health Branch is also investigating St. Joseph Hospital, although it won’t disclose why. Such investigations can involve failure to properly track radioactive materials.

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