Efforts to eliminate preventable hospital errors in Minnesota have taken on the appearance of the old arcade game Whac-A-Mole. Just as the state’s hospitals reduce deaths or disabilities attributed to one type of mistake, another pops up.
In the latest adverse-event report, released Thursday, Minnesota’s hospitals showed substantial progress in reducing the number of painful and disabling pressure ulcers that patients suffer because of immobility in hospital beds. They also reduced the number of surgical errors such as procedures on the wrong body part.
But increases in patient deaths or disabilities because of falls or medication errors countered the progress in other areas.
“These adverse health experiences are a wicked problem, in the common parlance,” said Dr. Ed Ehlinger, Minnesota’s state health commissioner. “They’re really complex. They’re [due to] multiple factors. They’re difficult to eliminate, but they are not totally intractable.”
Overall, the state reported 258 adverse events in the 12-month period ending Oct. 6 — an 18 percent decline from the previous year and the lowest total in five years. Preventable mishaps in surgery declined from 84 in the previous year to 61 last year.
The challenge of caring for increasingly frail and complex patients showed in the 10 deaths and 71 severe disabilities attributed to falls. Analysis of the falls concluded that a third of the patients were taking blood thinners, giving hospitals a new element to consider as they assess patients’ risks.
An additional five patient deaths related to hospital errors were reported last year — including two involving medication errors and one involving a woman who died during childbirth.
While acknowledging that one error is too many, hospital officials said patients are safer than they were 10 years ago when Minnesota first started publicly listing hospitals that committed any of 28 adverse events, also known as “never events” because they are considered preventable.
Surgeries to the wrong body part, for example, declined from 31 three years ago to 17 last year. But the numbers don’t tell the whole story, said Dr. Penny Wheeler, chief clinical officer of Allina Health, the system that runs Abbott Northwestern in Minneapolis and 12 other hospitals.
A decade ago, surgeries to the wrong body part might have involved extreme cases, such as the removal of the wrong breast during a mastectomy. Now, hospitals statewide mark incision sites to prevent such calamities, she said. More common examples of errors now include misplaced blocks for anesthesia or incorrect lens implants, which are fixable.
“That’s a little bit more subtle than I remember things 10 years ago,” Wheeler said.
Allina’s Phillips Eye Institute, for example, reported a paperwork mistake last year that led to anesthesia and drops in the wrong eye for a cataract surgery. The patient needed the procedure in both eyes, but on that day, it was just to take place in one eye, and it was done on the wrong one. Wheeler said the institute reinforced policies prohibiting the start of anesthesia before the surgeon arrives to confirm that the patient, procedure and procedure site are correct.
Mayo Clinic’s St. Marys Hospital in Rochester acknowledged a procedure on the wrong patient last year, something reported only 14 times in 10 years in Minnesota. A catheter was placed in the wrong patient, but in a bit of good fortune, it turned out he needed one as well.
Still, Mayo responded by adding a secondary level of confirmation in its electronic record-keeping systems before doctors can order procedures — in the same way that bank websites ask customers for passwords or birth dates.
“Fortunately, nobody was injured this time and nobody got anything they weren’t supposed to get,” said Dr. Timothy Morgenthaler, Mayo’s patient safety officer.
Last year’s error total was the lowest since 2008, when the state started requiring hospitals to report falls that caused disabilities — not just deaths — and expanded the definition of reportable bed sores.
Health officials have had the awkward task since that time of explaining how safety was improving if the total number of errors hovered above 300. They hope the decline in 2013 is a tangible sign of progress that will continue.
“Without this kind of effort, we would be seeing more harm and more deaths … than we are right now,” said Ehlinger, the state health commissioner.
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.”