Kaiser Permanente Medical Center in San Rafael has been fined $50,000 by the California Department of Public Health for failing to remove three to four inches of gauze from a patient after surgery.

The gauze was discovered and removed five weeks after the surgery.

The San Rafael hospital was one of 12 in the state disciplined for errors that were "likely to cause serious injury or death to patients," the California Department of Public Health announced Thursday. It was the first administrative penalty for the Terra Linda hospital.

The surgery took place some time in 2010.

State health officials don't specify the day in an effort to protect patient confidentiality.

The patient underwent laparoscopic surgery involving her gallbladder and kidney. Laparoscopic surgery is a minimally invasive procedure that employs a lighted scope and video camera.

According to the state Department of Public Health report, the patient "stated that the fifth week after surgery, she felt pain in her abdomen" and during an office visit her doctor "opened up the incision and pulled a long strip of gauze out of her abdominal area."

The report said "copious purulent material came out of the wound."

"The facility failed to develop, maintain and implement a surgical count policy that required all items used on the surgical field to be counted when a surgery was performed," the report said.


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Regarding this incident, Barbara Crawford, who oversees quality and regulatory services for Kaiser hospitals in Northern California, said, "When these incidents occurred in 2010 we took immediate corrective actions that were approved by the California Department of Public Health. To prevent a similar occurrence from occurring, our policies and training to prevent retained foreign objects have been broadened in scope to monitor and account for the type of material used in this procedure. The safety and well-being of our patients is our utmost priority."

Contact Richard Halstead via e-mail at rhalstead@marinij.com/