Hospital CEO says 1 error is too many

Published 10:15 am Friday, January 20, 2012

Mayo Clinic Health System in Albert Lea reported a single “adverse health event” in 2011, according to a report released Thursday morning by the Minnesota Department of Health.

Specifically, a doctor at the local medical center left an object in a patient. However, the report says it did not cause death or serious injury.

Dr. Mark Ciota, the chief executive officer at Mayo Clinic Health System in Albert Lea, said he is disappointed when the hospital even has just one. The hospital had zero last year.

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“We have to remember that these statistics are actually people, the people we failed, and I apologize for that,” Ciota said.

He said the patient is improving in condition. He said the object was a cotton towel much similar in size and feel to a handkerchief.

The Department of Health requires hospitals, surgery centers and similar places in Minnesota to report whenever one of 28 mistakes occur. It calls these mistakes “adverse health events” or sometimes “never events.” The data and background information is shared with all the other medical facilities in an effort to make sure they don’t happen again. The mistakes can range from surgery on the wrong patient to incorrect medication to getting air in the bloodstream to someone impersonating a doctor to a baby discharged to the wrong person.

Ciota said all sites of Mayo Clinic Health System, along with all Minnesota hospitals, strive for a perfect record. The shared information helps improve surgery and medical care in the state.

“Better isn’t going to be good until that number is zero every year at every site,” he said.

Steps have been taken to ensure objects are not left in a patient after surgery again. He said the towel was not an item on a checklist. It is now, and along with many other items that normally are not near the patient during surgery.

He said items are counted manually and electronically. A bar scanner device allows the surgery staff to take an inventory of everything in the room.

Serious mistakes in Minnesota hospitals rose slightly in 2011, but they led to fewer serious injuries and deaths than the year before, according to an annual report.

Hospitals reported 316 “adverse health events,” up from 305 the year before. Eighty-nine of the incidents resulted in serious injury or death, down from 107 the year before and the lowest number since 2007, the report from the Minnesota Department of Health showed.

The report determined that the overall increase in mistakes was due to more pressure ulcers — commonly known as bedsores — and “wrong procedures” performed on patients. But health officials trumpeted improvement in other areas: serious falls dropped 11 percent and wrong-site surgeries were down 23 percent.

 

 

About Tim Engstrom

Tim Engstrom is the editor of the Albert Lea Tribune. He resides in Albert Lea with his wife, two sons and dog.

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