Minnesota struggles to reduce medical errors

Minnesota hospitals and surgical centers reported 308 medical errors last year that risked patient safety.

Errors increased slightly over last year and are still rare, given the state's 2.6 million patient days.

But for patients on the receiving end of a mistake, the consequences can be severe. Last year 98 patients in Minnesota were seriously injured and another 13 patients died.

Minnesota's goal is to eliminate medical mistakes. But that task is proving stubbornly difficult, said Ed Ehlinger, commissioner of the Minnesota Department of Health.

"I don't think this is the best we can get," Ehlinger said.

This is the 11th year the health department has published the annual Adverse Health Events in Minnesota report. Since the state's adverse events reporting law took effect in 2003, medical facilities have improved their safety record.

Falls, pressure ulcers and wrong site surgeries have all declined. But other errors have increased slightly, including incorrectly placed catheters and feeding tubes.

The increase in some adverse health events can be explained in part by the addition of new types of mistakes that the state is now tracking, Ehlinger said.

When hospitals and surgical centers report an error, they must submit an analysis of how the problem occurred. Ehlinger said the findings often show that communication problems and faulty procedures were significant factors in the mistakes.

That was certainly the case this past year on the 20 occasions that facilities that lost irreplaceable patient lab specimens that included colon polyps, placentas and gall bladders, he said.

Ehlinger said the category was added to this year's report because it was only recently identified as a potential problem.

"We just took for granted that you get a specimen, it's going to show up in the lab and be processed," he said. "And now we find that that's not always the case. So the things that we assumed were in place, when we start looking at it, are not always there."

But fixing such problems is not as simple as creating new procedures or telling health workers to talk more to each other.

Even the best protocols can't guarantee that a mistake won't be made because health care workers are human and over time they naturally become less vigilant, said Kathleen Harder, director of the University of Minnesota's Center for Design in Health.

"It's not conscious; it's just something that occurs as people are doing the same sort of activity over and over," she said. "Again, they aren't aware that various elements aren't perhaps executed as well as they were in the beginning."

Harder said the safest hospitals and surgery centers tend to be the ones that pay constant attention to their policies and reinforce them regularly with staff.

Better hospital design can also help.

Minnesota's adverse health events data show that many hospital falls occur in and around bathrooms. This past year the Minnesota Hospital Association worked with an architectural firm to design safer hospital bathrooms.

Redesigning lighting is one way to prevent falls, said Dr. Rahul Koranne, the association's chief medical officer.

"Lights around the door for example to prevent folks from bumping in to the frame," he said. "The other was lights around where the switch is — so switching on the main, bright light."

Koranne said the association will publish its bathroom design tips online, so anyone can adopt the concepts to make their bathrooms safer.

Meanwhile, public health leaders say they haven't given up on the goal of achieving zero medical errors. But they say hitting that goal is a marathon, not a sprint.