"I'm not sure what we could have done differently," the operating room manager told investigators during interviews in August, a refrain echoed by others. "We trusted our surgeons."
The three cases, which involved two neurosurgeons implanting bowel bacteria into patients' brains, received so little scrutiny that the agency concluded all UC Davis hospital patients were at increased risk for infections and even death.
"(T)he hospital failed to effectively govern the activities and conduct of the hospital staff to provide safe and quality care to all patients," the report stated, describing the hospital's problems as "systemic failures."
University officials have rejected that sweeping assessment and have offered strong assurances that patient care at the medical center remains "excellent." The university has submitted a corrective plan to federal regulators to avert any loss of federal funding.