Minnesota hospitals report more errors in 2008

(AP) - Minnesota hospitals reported 312 serious problems - including 18 patient deaths - in the last year, according to an annual report released Friday.

The number of medical mistakes and other so-called "adverse health events" spiked considerably over the previous reporting period, but officials said the increase can be attributed to a new law that expanded what incidents hospitals should report to the Minnesota Department of Health.

Without the changes, officials said the number of incidents would have been 141 - slightly higher than the 125 incidents reported from October 2006 to October 2007.

During that period, 13 incidents were linked to patient deaths and 10 resulted in a serious disability.

Ninety-eight incidents in the most recent reporting period led to a serious disability, but that increase was also due to the expanded reporting requirements, officials said.

The 28 reportable incidents include surgery on the wrong body part, items like sponges or surgical objects left in a patient's body during surgery, bed sores and patient falls.

Much of the increase in incidents came from reporting falls that led to disability instead of just death and reporting a less serious stage of bedsore in addition to advanced bedsores.

By having hospitals report 28 preventable problems, the state hopes to gradually reduce the number of incidents and thereby improve patient care, said Minnesota Health Commissioner Sanne Magnan.

"We're always interested in what the numbers show, while also recognizing that these events are very rare," Magnan said. Hospitals in Minnesota recorded 2.8 million patient days in 2007, the latest number available.

"It's not just the numbers alone, but what we're learning from each incident," Magnan said, noting that the health department is celebrating the fifth anniversary of the reporting system. "This transparency and public reporting has persevered. ... The fact that we have a safe environment to talk about safety is something we should really be proud of."

Hospitals supported expanding the reporting requirements to include falls that lead to serious disability and "unstageable" pressure ulcers (a less advanced type of bedsore), said Lawrence Massa, president of the Minnesota Hospital Association.

"We're disappointed that the numbers went up slightly," Massa said. "But overall we've elevated safety and we understand these events better."

Massa said the hospitals were pleased to see a decline for the second year in a row in stage three and four pressure ulcers (the more advanced form of bedsores).

In addition, the number of retained sponges left in patients after childbirth declined, and all of those incidents occurred in the first half of the year, after which the hospital association sent an alert to its members to watch out for the mistake, Massa said.

The second-most errors - 37 - were reported by the Mayo Clinic's Saint Marys Hospital in Rochester, but the facility also sees one of the highest numbers of patients. Under the previous reporting requirements, the facility had 12 incidents the year before.

Dr. Michael Rock, chief medical officer for Mayo's Rochester hospitals, said the public will likely first see the jump in numbers. But he said Mayo's facilities and others are constantly improving patient safety, and that the transparency required by Minnesota law helps officials do that.

"Increasing the reporting requirements is only going to benefit patients and the institutions that care for them," Rock said.

In Rochester, health care workers have taken a closer look at reducing bedsores by alerting all medical staff involved in a patient's care when the person is first showing signs of the sores.

And to decrease falls, the hospitals are using innovations such as anti-slip tread on all sides of hospital-issued socks - just in case a patient puts them on upside down, Rock said. Health workers are also taking a closer look at patients with a history of falls, he said.

But the prevention of mistakes also has to do with a "change in a culture of safety," Rock said. In addition to reporting the incidents to the state, Mayo's Rochester facilities publish an internal newsletter includes information about each adverse event as it happens.

"That degree of transparency can't be underestimated," he said.

(Copyright 2009 by The Associated Press. All Rights Reserved.)

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