Nurses at Marin General Hospital are demanding action to resolve what they say are potentially dangerous patient care issues at the county's largest hospital.

Ten nurses voiced their concerns at Tuesday night's meeting of the Marin Healthcare District board. The district board oversees Marin General; but a separate board deals with the hospital's day-to-day operations.

Ninety nurses have signed a petition calling on the hospital to respond to a detailed list of issues affecting patient care. The nurses say many of the problems stem from inadequate staffing and continued difficulties utilizing the hospital's new computerized physician order entry system.

The nurses say they have been trying for over a year to get their concerns addressed. They tried to raise them at last week's meeting of the hospital's board of directors.

"They only allowed us five minutes," said Barbara Ryan, a registered nurse who serves as the hospital's California Nurses Association/National Nurses United representative.

Ryan said nurses feel hospital administrators are paying more attention to the hospital's financial performance than the quality of its patient care. In early February, a nursing administrator at the hospital sent emails to 44 nurses admonishing them for missed hospital charges, citing exact amounts in each case, and noting there would be training to correct the problem.

Responding to the barrage of criticism, Jon Friedenberg, Marin General's chief administrative officer, said, "Marin General Hospital has an exemplary record in terms of both patient outcomes and patient safety. For example, our cancer program has outcomes that are statistically significantly better than any other cancer program in the Bay Area, including those with the big names that are also excellent programs. And our patient safety record is exemplary."

The nurses paid a similar visit on the district board in May 2013 soon after a new computer system went into operation. At that time, they urged the hospital to put implementation of the computer system on hold until problems had been resolved and more training provided to nurses.

The nurses said Tuesday that major safety issues remain with the computer system. They say doctors are still entering orders inaccurately, and nurses and other personnel need more training.

But the computer system is just one of the problems cited by the nurses. Another primary concern is the care of patients with a history of cardiac problems.

"Sometimes there is just not enough room in the cardiac specialty unit and then they overflow the most stable of those onto the medical or surgical floors," Ryan said.

In other instances, doctors order the monitoring of patients who are in the hospital for an ailment unrelated to their heart because they have a cardiac history. In both cases, Ryan said the patients are monitored remotely.

"The monitors are at the nurses station or on a different floor entirely," she said.

Ryan said under state law the nurses taking care of these patients should have received advanced cardiovascular life support training, "and many of them have not."

She said nurses in the medical and surgical units are typically assigned five patients; but state law mandates that nurses responsible for remotely monitored cardiac patients be assigned no more than four patients.

"It's a safety issue," Ryan said, since changes in the condition of a patient being monitored remotely must be communicated to the bedside nurse, who in turn may need to call a doctor for instructions before administering a medication or injection.

Lynn Warner, a nurse in Marin General's step-down unit who spoke Tuesday night, said, "The nurses are stretched too far."

A number of the issues cited on the nurses' petition have to do with staffing. According to the petition, the hospital's intensive care unit and step-down unit are "very short staffed on a regular basis" and lack adequate support staff. The petition states that patients are being moved prematurely out of these units, which require higher nurse to patient staff ratios, to a lower level of care. The nurses also say the hospital is making "excessive use of travel nurses," instead of hiring local nurses.

Staffing also becomes an issue, the nurses say in their petition, when the hospital's emergency department holds patients awaiting a hospital room in the hallways from six to 12 hours. The petition states that in such cases emergency department nurses must care for seriously ill patients when specialty units — such as the intensive care unit, step down-unit or the cardiac specialty unit — have insufficient staff to float to the emergency department.

One significant issue was cited that is unrelated to either staffing or the new computer system: continued problems with processing of sterile instruments and other vital supplies in the hospital's operating room and ambulatory surgery center.

"The nurses are telling me that the instrument sets are often not complete," Ryan said. "They have the wrong instruments in them. The instruments are often not sterilized. There are holes in the packaging."

Roberta Hoffman, another Marin General nurse who spoke Tuesday night said, "It is very stressful when surgical instruments are not available and sterile before surgery. Dealing with this issue takes away from the attention that we would otherwise give to our patient."

Contact Richard Halstead via e-mail at rhalstead@marinij.com. Follow him at twitter.com/halsteadrichard