Sequoia Hospital fined for mistakenly removing woman’s ovaries

Sequoia Hospital in Redwood City mistakenly removing a woman’s ovaries in 2016. Sequoia Hospital in Redwood City mistakenly removing a woman’s ovaries in 2016. Photo: Liz Mangelsdorf, SFC Photo: Liz Mangelsdorf, SFC Image 1 of / 30 Caption Close Sequoia Hospital fined for mistakenly removing woman’s ovaries 1 / 30 Back to Gallery

California health officials have fined Sequoia Hospital in Redwood City $47,450 for mistakenly removing a woman’s ovaries in 2016.

The fine against Sequoia, which is owned by the Northern California health system Dignity Health, is one of 17 civil penalties lodged against 14 California hospitals for incidents that caused serious injury or death. The penalties against the hospitals, which total $1.1 million, were announced by the California Department of Public Health on Thursday.

Four of the 14 hospitals, including Sequoia, are in the Bay Area. The other three — which all had fatalities — are California Pacific Medical Center-St. Luke’s Campus and Kaiser Foundation Hospital, both in San Francisco and Queen of the Valley Medical Center in Napa.

Doctors at Sequoia were supposed to remove the patient’s uterus, fallopian tubes and appendix during a February 2016 surgery, but mistakenly removed her ovaries, according to a report from the California Department of Public Health. It is unclear whether the ovaries were removed in addition to, or instead of, the uterus, fallopian tubes and appendix. The report does not include the patient’s name or age.

MBA BY THE BAY: See how an MBA could change your life with SFGATE's interactive directory of Bay Area programs.

The procedure was entered incorrectly in the hospital’s surgical schedule, the report found, and the woman will need estrogen replacement therapy for life.

"The care and safety of our patients and staff are the highest priority at Dignity Health Sequoia Hospital and we take this matter very seriously," a Dignity Health spokeswoman said in an email. "After self-reporting this event to the CDPH, we fully cooperated during their investigation and immediately took steps to ensure this never happens again, including revising protocols and staff re-education."

Kaiser was fined $147,000 for two separate incidents that ended in patient deaths in 2015 and 2016. One involved a patient receiving dialysis whose line disconnected from his catheter, causing massive blood loss and cardiac arrest, the report found. The second involved the mishandling of a patient’s tracheostomy, a procedure to unblock the airways. St. Luke’s, an affiliate of Sutter Health, was fined $47,450 after a female patient fell in 2015 while under the care of hospital staff, hit her head, underwent brain surgery and died, according to the report.

“We sincerely regret that these incidents occurred and extend our sympathy to the families involved,” said a Kaiser spokeswoman. “In response to these incidents, and to ensure such situations never occur again, we immediately investigated their root cause, evaluated our processes and implemented systemic improvements and training for our nurses, physicians, and staff.”

A spokesman for Sutter said the hospital immediately reported the incident “to the appropriate regulatory agencies and initiated a quality improvement process to ensure it does not happen again.”

Queen of the Valley was fined $225,000 for three incidents in 2013 in which the staff failed to properly monitor patients’ symptoms or administered an incorrect treatment. Two patients died and the third is in a vegetative state, according to the report. A spokeswoman for the hospital did not immediately reply to a request for comment.

Catherine Ho is a San Francisco Chronicle staff writer. Email: cho@sfchronicle.com Twitter: Cat__Ho