Do no harm? Hospitals are at least doing less

Errors reported by Minnesota hospitals dropped by nearly 20 percent last year, suggesting that new patient-safety efforts are starting to pay off, according to a report released today by the Minnesota Department of Health.

The report, which tracks 27 ways that patients can be harmed in hospitals, found 125 incidents last year, down from 154 the year before. It was the first decline since the state started reporting hospital errors in 2005.

At the same time, 13 patients died and 10 suffered serious injuries as a result of those mistakes. The latest report detailed errors and incidents that are supposed to be preventable, such as medication mistakes, malfunctioning devices, falls and suicides, from October 2006 to October 2007.

"We are pleased that the numbers are going down," said Dr. Sanne Magnan, the Minnesota health commissioner.

This may well be a one-year blip, she said, but there's no question that the annual reports have prodded hospitals to examine what they're doing wrong and work together to change it. "I'm very encouraged by what we're seeing," Magnan said.

She said the number of errors will probably go up again next year because the state is expanding the types of incidents that must be reported. For example, this year it only tracked falls that resulted in a patient's death; next year it will include those that cause serious injury.

By law, every hospital and surgical center in Minnesota is required to report to the state 27 types of mistakes or preventable occurrences. They're known as "never events" in the industry, because they're never supposed to happen.

But they still do, as the latest report found: 24 cases of operating on the wrong body part, 10 wrong surgical procedures and 25 incidents of leaving objects behind in a patient -- usually surgical sponges or needles.

Last year, 38 Minnesota hospitals and four surgical centers reported at least one such event. They include some of the biggest and most prestigious hospitals in the state: St. Marys Hospital, part of the Mayo Clinic in Rochester, topped the 2008 list with 12 errors and three deaths.

Dr. Michael Rock, the chief medical officer at Mayo's two Rochester hospitals, noted that the errors are extremely rare given the "sheer volume" of patients -- more than 60,000 a year.

At the same time, he said, the reports have had a healthy effect on Mayo and the entire hospital system, forcing them to look for ways to improve. "We're already beginning to see some significant results from that," he said.

Projects to cut errors

Last year, the state hospital association launched three major projects to cut the number of falls, wrong-site surgeries and severe bedsores, also known as "pressure ulcers," the most common of the 27 never events.

When they compare notes, hospital officials say, they often find common causes, such as communication breakdowns and distractions that lead to errors in the operating room.

"Everybody is working on information overload," said Kathleen Harder, a University of Minnesota psychologist hired by the health department to try to diagnose the breakdowns in the operating room.

"A surgeon might have many different cases during a day [and] might be thinking about another case," she said. Even if hospitals have safety procedures in place, she said, they can break down: A staffer who suspects something wrong may be afraid to speak up.

"People aren't as vigilant as they should be when everything's routine," she said. "You just get into the flow and then something happens."

The solution, Harder said, is to create a work environment that helps people catch mistakes before they happen. Several years ago, she said, she and a colleague worked with Fairview's University of Minnesota hospital to reduce the number of objects left behind in surgery. Among other things, they introduced a huge whiteboard, which nurses use to track sponges and instruments, and insisted that they use it the same way, every time. The hospital has had only one such case since -- and it wasn't in one of the operating rooms, she said.

Alison Page, the chief safety officer for Fairview Health Services, agrees that hospitals are doing a better job preventing errors, thanks to the state scrutiny. "I think the public reporting and the transparency has been a great thing for hospitals," she said.

Few, though, think the "never events" will ever disappear. They'll always be rare, Page said. But "I don't think we will ever get to zero."

Maura Lerner • 612-673-7384