Report: Hospital mistakes in Minn. down slightly

Hospital mistakes that put Minnesota patients at risk of serious injury or death dipped slightly last year, according to a state Department of Health report to be released Thursday.

The study, which looked at hospital errors from Oct. 7 2008 to Oct. 6, 2009, found 301 errors or events that compromised patient safety.

Four patients died as a result of hospital mistakes -- the lowest number of deaths caused by preventable events on record, the study said. That's down from an average of nearly 13 patient deaths in each of the past 5 reporting years.

The state's report tracks serious problems like medication errors or wrong-patient, wrong body-part surgeries. It also tallies falls. Of all 28 reportable adverse events, falls are the most likely to lead to significant disability or death in the hospital.

Among the bright spots in this year's report: falls decreased by 20 percent. There also were no patient deaths attributed to hospital falls last year.

"That's another encouraging sign," said Dr. Sanne Magnan, Commissioner of the Minnesota Department of Health. "But we're certainly by no means claiming victory."

Magnan is cautious about making too much of the in hospital deaths caused by errors. Ideally, there would be no mistakes or adverse events, she said.

But hospitals are still learning about some of the ways that patients can be harmed in their facilities.

For example, the state's reporting system revealed this year that 13 percent of bed sores were caused by surgeries that last a long time. For some high-risk patients a long time could be as short as an hour or two spent in the pre-operation room and in surgery.

That's quite a revelation, Magnan said.

"Who's thinking of skin breakdown in a healthy person who's going for surgery? But that's what we found as we were digging in to the information," she said.

Most of the patient injuries in the study were caused by mistakes that could have been prevented if doctors or nurses had just followed procedures, the report said.

During the past year, cases in which doctors performed the wrong procedure or operated on the wrong patient or body part increased from 39 the previous year to 44 cases in 2009.

"That's probably the most disappointing piece of this report is the increase in wrong-site, wrong-patient," said Lawrence Massa, president of the Minnesota Hospital Assoication. "It's very frustrating and we plan to work on that and make that a priority in this coming year."

Massa, whose industry group represents most of the state's hospitals, said even though there were more wrong-patient, wrong-site procedures, the good news is that overall the consequences for patients weren't as severe.

"We're finding in a lot of these reported events the procedure was not completed," Massa said. "They realized that they had erred and stopped the procedure early on. And that's not reflected in the data. But that's at least something that we're seeing from the detail that we look at."

Still, the goal is to make hospital safety policies error-proof.

In their search for a better way to count surgical sponges, two Twin Cities-area hospitals are experimenting with plastic bags that contain pockets. Each pocket holds an individual sponge. At the end of a surgical procedure a nurse can look at the pockets to see if all of the sponges have been removed from the patient. The technique eliminates the need for counting, which is easy to mess up.

But the results aren't coming fast enough for some Minnesotans.

"Well okay, we're doing better. Now it's time to really crank it up," said Carolyn Pare, CEO of Buyer's Health Care Action Group. The coalition of employers works to improve health care quality.

As a business person, Pare said she has a hard time understanding why it's taking hospitals so long to fix patient safety problems. She thinks that after six years, Minnesota hospitals should be performing much better.

"I would really challenge us as a community to push really hard to make let's say one or two of them just go away," she said. "That would be a significant achievement."

Pare said it is legitimate for patients to use the information in the report to choose a hospital because the events described in the report should never happen.

But Magnan said hospitals have been the driving force behind expanding some of the reporting requirements so they could learn more from their mistakes. It would be unfortunate to penalize them for doing the right thing, she said.

The adverse health events report is posted on the Minnesota Department of Health's Web site.