TY - JOUR PY - 2022// TI - Morbidity and Mortality Caused by Noncompliance With California Hospital Licensure: Immediate Jeopardies in California Hospitals, 2007-2017 JO - Journal of patient safety A1 - Zheng, Micha Y. A1 - Lui, Hansen A1 - Patino, German A1 - Mmonu, Nnenaya A1 - Cohen, Andrew J. A1 - Breyer, Benjamin N. SP - e401 EP - e406 VL - 18 IS - 2 N2 - 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
LA - en SN - 1549-8417 UR - http://dx.doi.org/10.1097/PTS.0000000000000822 ID - ref1 ER -