In 2006, California passed a disclosure law that requires hospitals to report each time a patient suffers certain adverse events caused by inadequate medical care. As data has become available for a 10 month period beginning in July 2007, more than 1,000 such events have been documented and ten hospitals have been fined $25,000.

Some of the events reported include:

• Too little oxygen being pumped via ventilator hose to a 9-day-old child; the diagram for assembly was drawn backwards.
• Surgeons removed the appendix of the wrong patient when a CT scan was placed into the wrong patient file.
• A 76-year-old woman died when she was given two drugs her doctor never prescribed.
• 466 patients developed bed sores so severe that dead skin formed a crater in the patient’s skin or it rotted entirely through to the patient’s muscle and bone tissue.
• 145 surgical patients left the operating room with foreign objects, including surgical instruments, still in their bodies.

Investigation revealed that these events happen when hospitals do not follow the safety procedures that were developed to prevent them.