Citation

Zheng MY, Lui H, Patino G, Mmonu N, Cohen AJ, Breyer BN. J. Patient Saf. 2022; 18(2): e401-e406.

Copyright

(Copyright © 2022, Lippincott Williams and Wilkins)

DOI

10.1097/PTS.0000000000000822

PMID

35188929

Abstract

OBJECTIVE: The California Department of Public Health investigates compliance with hospital licensure and issues an administrative penalty when there is an immediate jeopardy. Immediate jeopardies are situations in which a hospital's noncompliance of licensure requirements causes serious injury or death to patient. In this study, we critically examine immediate jeopardies between 2007 and 2017 in California.
METHODS: All immediate jeopardies reported between 2007 and 2017 were abstracted for hospital, location, date, details of noncompliance, and patient's health outcome.
RESULTS: Of 385 unique immediate jeopardies, 141 (36.6%) caused mortality, 120 (31.2%) caused morbidity, 96 (24.9%) led to a second surgery, 9 (2.3%) caused emotional trauma without physical trauma, and 19 (4.9%) were caught before patients were harmed. Immediate jeopardy categories included the following: surgical (34.2%), medication (18.9%), monitoring (14.2%), falls (7.8%), equipment (5.4%), procedural (5.4%), resuscitation (4.4%), suicide (3.9%), MD/RN miscommunication (3.4%), and abuse (2.3%).
CONCLUSIONS: Noncompliance to hospital licensure causes significant morbidity and mortality. Statewide hospital licensure policies should focus on enacting standardized reporting requirements of immediate jeopardies into an Internet-based form that public health officials can regularly analyze to improve hospital safety.

Language: en

Keywords

Humans; Morbidity; California; Hospitals; Hospital Mortality; Licensure, Hospital