Health Department: Medical errors on the rise in Minnesota

Medical errors are on the rise in Minnesota, according to a report out Friday from the Minnesota Department of Health.

This past year, the numbers were the highest since hospitals began tracking 15 years ago.

From October 2017 to October 2018, there were 384 "adverse health events." They included 118 serious injuries and 11 deaths. Five of the deaths were the result of serious falls; three were newborns who were expected to have a healthy delivery; two were medication errors; and one death was a suicide.

"Given the number of patients that we serve — 5 million patient days in this reporting period — these events remain extremely rare," said Dr. Rahul Koranne, chief medical officer of the Minnesota Hospital Association. "While every single one of these numbers represents a patient, a family, a care team and a community, we've done an incredible job in the last 15 years of holding these numbers down."

For people working on these reports, the numbers can be frustrating.

"What you see in the numbers is that they're not changing very much. But what you don't see is all the activity that's gone on to change the very nature of those events," said Marie Dotseth, assistant commissioner at the Minnesota Department of Health. "We know that there's a lot of progress but we also see that the way we're tracking it — it doesn't show up in the numbers."

One problem area hospitals have been working on is foreign objects such as sponges or clamps getting left in a patient's body after surgery. It's now standard practice for two staff members to count every item used in a surgery before and after the procedure to make sure nothing gets left behind. Rachel Jokela, director of the state department's Adverse Health Events Program, said results have improved dramatically, but you won't see that looking at the numbers.

"What happens now more often is that it's actually broken items, so it might be the tip of a catheter that's used. So, when they're counting it, they still have the one catheter so it looks like they have everything they need, but the tip is missing," said Jokela.

She said it's increasingly rare that a second surgery is required to go back and retrieve an item. And now some hospitals are photographing every medical instrument before use to make sure nothing broke off while it was used.

The most common adverse health event by far was pressure ulcers — commonly called bedsores — although they're not just from being in bed too long. They typically occur when pressure is applied to a certain part of the body for a long time, often along with the presence of moisture. Brianna Skrukrud, a nurse practitioner with Mayo Clinic, said 60 percent of pressure ulcers show up at the very base of the back, at the top of the buttocks, in acutely ill patients who are too sick to move.

"And so basically it makes us wonder if any patient that's going to the ICU or becoming acutely ill that we place a certain dressing — a five-foam-layer dressing — to that region to help prevent it," said Skrukrud.

About a third of pressure ulcers result from prolonged contact with medical devices — breathing machines, feeding tubes, bedpans or neck braces. Such sores can become serious but are seldom fatal.

While there's no conclusive research, physicians offer plenty of anecdotal data as to why the numbers are going up. The population is aging; obesity rates are also on the rise; and people coming to hospitals are generally coming in with more severe and complex health emergencies and are staying for longer periods of time.

Assistant Commissioner Marie Dotseth said the state Department of Health plans to convene a series of conversations this year around the state to discuss how medical errors are reported.

"We know that health care has generally changed a lot in the last 15 years and specifically the science of patient safety has changed a lot in the past 15 years," said Dotseth. "And we'd just like to engage in a broader community conversation with various stakeholders across the state to see if this is still the best way to track our events and to address safety issues."