The Minnesota Department of Health’s annual report on adverse health events in the state included one event listing at Mayo Clinic Health System in Albert Lea and three listings in Austin.

“That’s a rallying moment for us to carefully examine our systems of care,” Mayo Clinic Chief Patient Safety Officer Dr. Timothy Morgenthaler said of the report.

At the Albert Lea campus, the Department of Health’s report, including incidents that occured between Oct. 7, 2016, and Oct. 6, 2017, listed one fall that resulted in serious injury. The Austin campus also reported a fall that resulted in a serious injury.

Morgenthaler said patient falls are a challenging problem across the United States.

“Oftentimes patients are falling when they are close to discharge, or when they weren’t really assessed to be at a particularly high risk for falls,” he said. When people are admitted to the hospital, they are “by definition, ill.” Additionally, patients may be used to higher levels of independence compared to their condition in the hospital.

Morgenthaler said fixing the problem is a challenge, but educating patients about their fall risk could be a component. The Mayo Clinic Health System has also taken steps to increase the visibility of fall risk within its staff, Morgenthaler said.

According to the Minnesota Department of Health’s report, 2017 was the second year of an increase in falls in reporting Minnesota health facilities.

In addition to a reported fall, Mayo Clinic Health System in Austin also reported an irretrievable loss of an irreplaceable biological specimen and a wrong surgical/invasive procedure performed.

Of the incidents involving irretrievable losses, the Minnesota Department of Health report said 54 percent of the specimen loss or damage occurred during obtaining specimen collection, 31 percent during the processing of a specimen and 15 percent during internal transport. Of those specimens, 77 percent were lost, and a smaller percentage of them were destroyed or damaged to the point where they could not be tested.

Often, Morgenthaler said, specimen loss is due to system issues. For instance, there may be one system on which a person ordered a specimen and another tracking where that specimen went. Mayo Clinic Health System’s conversion over to Epic, a healthcare software system, may improve that, Morgenthaler said.

The four incidents between Albert Lea and Austin are part of a rise in reported incidents from the previous year’s report.

““The recent rise in adverse events it concerning,” said state Health Commissioner Jan Malcolm in a press release. “Minnesota can and must do better to protect vulnerable patients. We will continue to work with our partners to improve patient safety and the quality of care.”

According to Morgenthaler, Mayo Clinic Health System employees are committed to ongoing improvement and learning.

“We’ve always been glad and proud to participate in the reporting system,” Morgenthaler said. “We consider transparency is just so important in improving and maintaining the trust of our patients. … We are very motivated to get things right.”