Annual statewide report shows spike in medication errors during previous year.
Serious medication errors rose sharply in Minnesota hospitals last year, even though many hospital pharmacies have converted to sophisticated new electronic dispensing systems.
Minnesota's annual report on adverse events -- a public accounting of preventable errors by hospitals -- shows 13 serious medication errors in the year ended last Oct. 6. By comparison, only 14 medication errors were reported in the previous three years combined.
Simple medication errors can result in patients receiving toxic doses, or in receiving new drugs that produce harmful interactions with old ones. Such mistakes were the second-leading cause of death among the 28 preventable errors the state has recorded since 2005.
"Medication errors are challenging because there are so many points at which they can happen," from the pharmacy to the patient's bedside, said Diane Rydrych, assistant director for the state Health Department's policy division.
The rise in medication errors was the most notable development in this year's report, which otherwise showed little change in the occurrence of "never events," so-called because they are never supposed to happen. These include surgeries on the wrong body parts, assaults on patients, and fatal and disabling falls. The 305 total events in this year's report compare with 301 events reported for 2009 and 312 for 2008.
The report said 10 deaths and 97 serious disabilities resulted from hospital errors. Medication errors accounted for two of those deaths and 11 disabilities.
As in past years, the hospitals with the most errors were among the state's busiest -- and most prestigious. The University of Minnesota Medical Center had the most preventable errors, 40, including one death from a medication error. The Mayo Clinic's St. Marys Hospital in Rochester logged 33 errors, including one death from a fall. Hennepin County Medical Center came in third, with 27 errors, none fatal.
Hospital leaders said they're making progress on patient safety, although the number of adverse events isn't declining. (This year the state reported 80 patient falls, for example, including five that were fatal, compared with 75 falls and no deaths in last year's report.) Rydrych said hospitals discovered that many of the falls occurred a day or two after patients had surgery, when they believed they were strong enough to get up on their own. Hospitals are asking their nursing staffs to train patients on the importance of asking for help in such recovery phases.
The hospitals also discovered that half of the reportable falls involved patients on "culprit medications" such as sedatives.
No such pattern emerged in medication errors as the Health Department and hospital leaders studied the data, Rydrych said. The state, as a result, was unable to issue any meaningful alert to hospitals about what to do to prevent future occurrences.
"It was just a cluster that happened this year that had no common thread to it," she said.
Medication errors have long been a hobgoblin for hospitals, and an early target for prevention efforts. The U.S. Institute of Medicine conservatively estimated that 400,000 preventable drug-related injuries occurred in hospitals in 2006 at a cost of $3.5 billion in excess medical costs that year.
Even something as simple as sloppy handwriting by a doctor can result in a severe medication error -- especially when drugs such as clonidine and Klonopin have such similar names. Simple math errors in dosage formulations can have fatal outcomes, as well.
Eight of the 13 medication errors reported this year occurred at Fairview hospitals, including four by the University of Minnesota Medical Center. Deb Cathcart, a member of Fairview's patient safety team, declined to offer specifics on the incidents, but said that each was investigated and that patients or relatives were notified. The hospitals frequently send out reminders about ways to reduce medication errors, she said, such as using "Tall Man Lettering" that clearly distinguishes drug names on written orders.
Fairview hospitals are installing the Epic electronic medical-recordkeeping system, which among other things will allow caregivers to use bar-code scanning to match patients to the proper medications.
All hospitals are also in the process of meeting a state mandate for computerized prescribing systems as of Jan. 1. While the systems aren't foolproof, Rydrych noted that they can issue alerts to doctors who enter dosages that appear questionable or order drugs that would cause harmful interactions with other drugs that patients are taking.
Staff writer Maura Lerner contributed to this report. Jeremy Olson • 612-673-7744
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