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Los Angeles hospital in trouble after surgery glitch

Hospital Safety Connection, July 16, 2004

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Surgeons at Martin Luther King Jr./Drew Medical Center in Los Angeles mistakenly left a metal clamp pen inside a patient two weeks ago after emergency surgery for multiple gunshot wounds, the Los Angeles Times reports.

Last week, when the patient had a chest x-ray, doctors noticed and removed the clamp pen. County health officials said the patient received no injuries as a result of the surgery glitch.

"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."

This isn't the first time staff at MLK/Drew Medical Center made mistakes in patient care. A few months ago, a patient with meningitis received a potent cancer drug. Previous government inspections found that five patients died after being neglected by nurses and others, county supervisor Zev Yaroslavsky said.

"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."

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