San Diego County physicians and healthcare professionals are facing renewed concerns about transparency and patient safety after significant lapses in care at local hospitals were only recently made public—years after the incidents occurred. According to the San Diego Union-Tribune, two recent penalties posted by the California Department of Public Health (CDPH) reveal troubling delays in reporting these incidents.
On August 20, CDPH levied $87,500 in fines against UC San Diego’s Hillcrest Medical Center for severe lapses in patient care that occurred in 2019 and 2020. The violations include a patient’s death following equipment failure during cardiac resuscitation and a surgical error involving a cystic fibrosis patient. These findings come just months after a June notice of a penalty against Paradise Valley Hospital, where failures in care contributed to a baby’s death in 2016—eight years before officials informed the public.
“Incidents like these bring to light the critical need for timely public disclosure,” said San Diego-based patient advocate Marian Hollingsworth. “If the UCSD citations had been released sooner, patients with heart conditions could have made informed decisions about their care. Delayed reporting robs patients of the ability to provide true informed consent.”
CDPH cited the COVID-19 pandemic as a reason for the delayed release of these reports, particularly the 2020 incident. However, officials did not explain the delay in the 2019 case. “The pandemic created unprecedented challenges, resulting in delays in issuing citations and penalties,” CDPH said in an email.
Physicians know that administrative penalties often serve as the first opportunity for the public to learn about severe incidents in state-regulated hospitals. Civil lawsuits related to these lapses in care are usually settled out of court, leaving few details available to patients and families. However, such incidents also factor into hospital quality reporting and influence metrics like the rate of medical errors routinely provided to state and federal regulators.
UC San Diego Health’s Hillcrest Medical Center has consistently performed well in national hospital safety assessments despite these troubling incidents. The Leapfrog Group, a nationwide hospital quality assessor, awarded the facility straight “A”s in its Hospital Safety Grade program from 2021 to spring 2024. In a written statement, UC San Diego Health acknowledged the penalties after receiving notification in May 2024 and emphasized its commitment to patient safety.
“Both cases were self-reported. The safety of our patients is always our top priority, and we have worked closely with CDPH to address the concerns raised. Corrective action plans have been implemented, and we are pleased they were accepted,” the statement said.
One of the incidents involved the death of a cardiac patient on August 7, 2019. The patient, admitted with symptoms of cardiac distress, was found unconscious in their room, prompting a “code blue” emergency. According to CDPH’s investigation, nurses attempted to use a newly purchased defibrillator to restore the patient’s heart rhythm. Still, the equipment failed because the pads were incompatible with the new defibrillator. The resuscitation was unsuccessful, and the patient died.
On January 1, 2020, a surgical mix-up occurred. The medical team scheduled a cystic fibrosis patient for port removal but instead inserted a new port. According to the CDPH report, a medical resident misinterpreted the patient’s documentation and revised the consent form after administering sedatives. The pre-surgery “time out” procedure, which aims to prevent such mistakes, failed to catch the error. The patient, understandably traumatized, required a second surgery.
These incidents underscore the importance of holding healthcare systems accountable for the quality and timeliness of care provided. For physicians, the lessons are clear: timely communication and adherence to safety protocols are critical to maintaining patient trust and avoiding preventable errors. As healthcare professionals, we must remain vigilant and advocate for transparency to protect the well-being of those we serve.