For Days, Potent Drug Given to Wrong King/Drew Patient

Surgeons at Martin Luther King Jr./Drew Medical Center mistakenly left a metal clamp the length of a ballpoint pen inside a patient two weeks ago -- another in a series of lapses to occur despite the hospital’s vows to fix failings in patient care.

The clamp was left inside the unidentified patient during emergency trauma surgery for multiple gunshot wounds at the Los Angeles County-owned hospital. The error was discovered last week, when the patient underwent a chest X-ray in preparation for another surgery, county health officials confirmed Monday. The clamp was removed, and the patient does not appear to have suffered injury, the officials said.

A clamp looks like a pair of scissors but does not have sharp edges; it is used to cut off blood flow to specific areas during surgery. Leaving tools inside a surgical patient is rare, occurring in as few as one in 1,500 abdominal surgeries, studies show.

“That just shouldn’t happen,” said Dr. Kenneth W. Kizer, president of the National Quality Forum in Washington, D.C., a patient safety group, and a former California health director. “In this patient, maybe it didn’t cause any harm; the next one might not be so lucky.”

County Supervisor Zev Yaroslavsky said the incident cannot be viewed in isolation, given King/Drew’s recent history of mistakes and patient-care violations. Just a few months ago, for instance, a meningitis patient was mistakenly given a potent cancer drug. Shortly before that, government inspections found that five patients had died after being ignored or neglected by nurses and others.

“If there’s one thing that has been certain at King/Drew over the last few years, if not longer, it’s that aberrations happen too often, and that is obviously of great concern and frustration,” Yaroslavsky said. “I’m really just at my wit’s end.... It doesn’t seem to stop. It doesn’t seem to end.”

Surgical teams are generally expected to count sponges and instruments before, during and after operations to ensure that none are left inside the patient. In the urgency of trauma surgeries, such counts sometimes cannot be done. In those cases, doctors are expected to order a post-surgical X-ray to ensure that no tools were left behind, said John Wallace, spokesman for the county Department of Health Services .

That did not happen in this case, Wallace said. The X-ray that caught the error was needed for an upcoming surgery.

The hospital did not notify the state Department of Health Services about the error, as is expected in such cases, said Jackie Lincer, a district manager in the agency’s Orange County office. Los Angeles County officials said they were under no obligation to inform Lincer’s agency.

Court records indicate King/Drew has made similar mistakes in recent years. Los Angeles County has settled four lawsuits in the past three years involving catheters and other objects left in patients during surgeries. Within the last year, a man was paid $50,000 because of a catheter left inside him for at least six years. The catheter was not discovered until 2002, when he complained of abdominal pain and bloody diarrhea.

Dr. Thomas Garthwaite, director of the Department of Health Services, said he could not say if King/Drew’s surgical mistakes and other problems were more pronounced than those of other hospitals. The problems do, however, receive more media attention, he said.