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More work needed on falls
Reducing falls remains a challenge, especially as more hospital patients tend to be older, sicker and weaker. Allina Hospitals and others are assessing patients early for fall risks and giving them red socks so staff can watch for them. The University of Minnesota Medical Center, Fairview, improved supervision of patients during shift changes so they wouldn’t try to get up or go to the bathroom unsupervised. Lakewood Health System in rural Staples, Minn., used a state grant to purchase equipment that stabilizes and protects patients from falls during physical therapy.
But the state adverse-event report noted that some of the basics aren’t being done. While most patients who suffered fatal or disabling falls last year were assessed for their risks, less than half had been placed in beds that could be lowered to the floor to reduce the potential for harm if a patient were to fall out of bed. None had protective floor mats below their beds, either.
The report of nine medication errors resulting in deaths or disabilities last year was the second-highest total in 10 years of reporting.
Most large hospitals have digitized their prescribing systems, so that bar codes can be used to verify that drugs are matched to the correct patients. But the adverse-event report, produced by the state Health Department and the Minnesota Hospital Association, showed that errors happened anyway.
In one instance, a staff person chose the wrong medication off a cart during an emergency. In another, a doctor ordered a medication before reviewing a patient’s chart that would have showed the drug would be harmful.
Fairview’s University Hospital reported five medication errors and 26 errors overall. It often reports the most errors of any hospital, in part because it treats the highest number of patients and some of the most challenging cases. But last year’s result was a decline from 35 errors the previous year.
Whether the high numbers look bad, the reality is that the aggressive reporting has made the hospital safer and has contributed to the “knowledge base” in Minnesota that has made all hospitals safer, said Carolyn Wilson, president of the medical center.
“We’re willing to take the risk, if you will, that people might misperceive” the results, she said, “because we think patient safety is the ultimate.”
Jeremy Olson • 612-673-7744