Patient hospital safety improves, but falls remain a problem

The number of deaths and harmful events linked to preventable hospital errors has largely declined in the past decade, according to a new report from the Minnesota Department of Health.

Department officials, who have tracked so-called "adverse health events" since 2003, called the trend encouraging. Still, the pace of progress has been slower than many health care leaders would like.

State law requires hospitals and ambulatory care centers to track more than two dozen types of serious health care events, situations that should rarely or never happen. They include wrong-site surgeries, foreign objects left in patients, medication errors, and falls.

Since the reporting requirement took effect, the number of preventable patient deaths associated with such events has declined from 25 in 2006 to five in 2011. But patient deaths increased in 2013, when 15 were attributed to preventable hospital errors.

"I think the progress has been slower because we didn't fully grasp how complex some of these issues are," said Lawrence Massa, president of the Minnesota Hospital Association.

Ten of the 15 patient deaths in 2013 were due to falls, a particularly challenging problem for hospitals, Massa said.

Members of his association have adopted detailed strategies to prevent falls, but Massa said the problem persists.

"In many cases the hospital said 'we did all of those things, but yet the patient still fell.' So I think there's this frustration," he said.

Some Minnesota hospitals are using their electronic medical records to identify patients who might be a fall risk. They also post alerts on patients' doors and give them red socks, so staff members can easily identify vulnerable patients who are walking outside of their rooms.

Penny Wheeler, president and chief clinical officer of Allina Health, said ensuring patient safety requires hypervigilance.

"It takes everybody doing things consistently, and consistently well for each and every person we touch, and following the safest of practices and speaking up when we see something that could be done better," Wheeler said.

Patients also need to speak up, said Ed Ehlinger, commissioner of the Minnesota Department of Health. If they can't advocate for themselves, he said, family members should do what they can to make sure their relative is protected from preventable errors.

"They should ask questions. They should ask the facility about what their safety procedures are," Ehlinger said. "Are they following best practices? And be aware that they can say, 'Grandma is old and she has some dementia and I'm worried about falls, please pay attention.' And the hospital should respond to that."

While the report shows that there's a lot more work to be done, Ehlinger said the analysis does suggest that Minnesota's reporting law has improved safety for patients.

In 2013 for example, there were 258 serious health events. That was a decline of 18 percent from the previous year. It's also the largest year-to-year drop since the reporting system was launched.

That, combined with a trend that shows an overall decline in bad patient outcomes, has public health officials, hospitals and patient advocates feeling good about the direction of the program.

Marie Dotseth, executive director of the Minnesota Alliance for Patient Safety, called the drop a public policy victory. She said 10 years ago it was difficult to convince anyone in health care to talk openly about a medical error, especially if it caused harm to a patient. But she said Minnesota's reporting requirement has made those conversations easier and fostered an overall culture of safety in hospitals.

"It catalyzed a whole other conversation around patient safety improvement generally, made it a higher priority perhaps in some organizations," Dotseth said.

The Minnesota Department of Health is exploring the possibility of expanding the law's reach to include other health providers in the state such as long-term care facilities and clinics.