Medical mistakes up in Minn.

Published 11:48 am Thursday, January 19, 2012

MINNEAPOLIS — 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 so-called “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.

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“We were very pleased to see that the overall level of harm that was reported … was down, even though the total number of events was up,” said Lawrence Massa, president and CEO of the Minnesota Hospital Association.

State law requires hospitals and ambulatory surgical centers to report serious mistakes and investigate why they happened. The report examines potential errors in six categories: surgical, environmental, patient protection, care management, product and device, and criminal events. It covers the period roughly from October 2010 to October 2011.

“Wrong procedures” differ from wrong-site surgeries, in which surgeons may, for example, mistakenly operate on a patient’s left leg when the right leg was the target. Wrong procedures occurred 26 times, a 63 percent jump.

Massa said the mistakes can occur because of miscommunication between clinics and hospitals during the scheduling of surgeries and other invasive procedures. He said hospitals are increasingly adopting the World Health Organization’s Surgical Safety Checklist, a series of preventive steps before each surgery, including a “time out” to identify the patient and procedure before picking up any instruments.

Pressure ulcers made up the largest share of the medical mistakes: 141, a 19 percent increase from the year before.

Though they may seem minor, pressure ulcers can lead to infection, prolonging hospital stays and taking a long time to heal, said Dr. David Bates, director for the Center for Patient Safety Research and Practice at Brigham and Women’s Hospital in Boston. But they remain a universally stubborn problem for many hospitals, he added.

“The issue is that patients who are immobile are at risk for developing pressure ulcers. Yet it’s hard to tell who is really having problems with moving,” Bates said.

Regions Hospital in St. Paul saw its pressure ulcers drop to five, down from eight last year. Officials there say they’ve made preventing bedsores a priority with a program launched last March, and they showed their methods to a reporter visiting on Wednesday.

During a routine check on a neurosurgery patient in intensive care, doctors and nurses examined the heels, lower back and tubes resting on the face, all common ulcer points. The patient’s limbs and body were propped at an angle to avoid a large bed-to-body surface.

Patients are repositioned and checked every two hours to prevent pressure ulcers from forming.

“My mantra is E-cubed,” said Bruce Bennett, director of Regions’ surgical intensive care unit. “See every inch of every patient every day.”

During long surgeries where patients are difficult to move but pressure ulcers are still a risk, Regions uses foam and gel-topped surgery tables with additional gel pads to maneuver body parts.

The Minnesota Health Department said Minnesota hospitals reported about 2.6 million patient days in 2010 and more than 10 million outpatient registrations, and ambulatory surgical centers reported more than 216,000 registrations for same-day surgeries.


What about Albert Lea?

The report, released to the public this morning, states Mayo Clinic Health System in Albert Lea had one adverse health event — a foreign object left in a patient. It did not cause death or serious disability. The Tribune intends to speak with the medical center officials about the Minnesota Department of Health report, as it does annually.