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Phillips Eye Institute uses a series of protocols to actively prevent medical errors.

Renee Jones Schneider, Star Tribune

Hospital error rate in Minnesota isn't improving after 9th report

  • Article by: JEREMY OLSON
  • Star Tribune
  • January 31, 2013 - 7:58 AM

Hospitals can require doctors to pause and double-check their procedures -- and yet 53 times last year they performed the wrong surgeries on Minnesota patients or cut into the wrong body parts. Nurses can be required to check every 30 minutes on patients too weak to walk -- and yet six patients died and 73 were severely disabled by falls.

Minnesota's latest annual report on adverse medical events shows that after nine years of owning up to mistakes, hospitals and surgery centers are still making the same rare but severe errors in patient care.

Seventy-five hospitals committed 314 reportable errors in the 12-month period ending Oct. 6. Fourteen involved patient deaths and 89 resulted in severe injuries. The prior year, hospitals reported 316 such errors, and only five deaths.

"We're still at a level that is too high," said Dr. Ed Ehlinger, state health commissioner. "These are things that shouldn't be occurring."

The numbers frustrate state hospital leaders, who have adopted comprehensive reforms to stamp out preventable mistakes. The numbers also reflect the frailty of such safety efforts if doctors or hospital workers don't follow them properly.

Four of five mistakes involving the wrong procedure or wrong body part, for example, occurred despite mandatory "time-outs" -- pauses when surgical teams verify they're about to do the right procedure on the right patient.

"The fact that you did the time-out doesn't tell us the quality of how that was done," said Lawrence Massa of the Minnesota Hospital Association.

Hospital workers can lose vigilance, especially with errors that might happen once every 10,000 procedures. But often they don't understand the time-out process in the first place, said Kathleen Harder of the University of Minnesota's Center for Design in Health.

Before surgery, a doctor now marks the site of a procedure in ink and has the patient initial it. But the doctor is supposed to review that mark one last time before starting any procedure.

"If the site mark is not visualized during time-out, and a team member relies on memory, that's a problem," said Harder, who was dispatched by the Health Department to observe hospital time-outs throughout Minnesota. "If that step is missed -- and I have seen it missed -- then wrong-site surgery can occur."

The right lens

At the Phillips Eye Institute in Minneapolis, leaders audit one in 20 procedures to make sure time-outs are done properly, and they have ordered surgical teams to do them over.

Last year, eight of the 30 wrong-procedure cases in Minnesota involved implanting incorrect ocular lenses in patients' eyes. But Phillips hasn't reported such a case since 2008, when it created a set of steps to prevent the mix-up.

Previously, surgeons would bring all of their lenses for the day into an operating room and stack them in order. If one patient canceled, the sequence was fooled. Surgeons now complete reservation forms in selecting lenses; the forms stay with the lenses until the implants take place.

Last year, all of Minnesota's incorrect-lens cases occurred before May 12 -- the date the state urged hospitals to mimic Phillips' safety steps.

There were other signs of progress last year: No procedures were performed on the wrong patients and serious medication errors dropped from 13 in 2010 to two in 2012.

Under state law, hospitals must report any of 28 adverse events. Hospitals reported two patient deaths by suicide last year and three patients who suffered severe burns. Two patients died and two were severely injured by intravascular air embolisms -- air bubbles that lodge in the heart due to medical or surgical missteps.

Before those embolism cases, only seven had been reported in the previous eight years.

But even rare events prompt change. Three of the embolisms occurred at Mayo Clinic hospitals in Rochester, and two involved staff members removing central venous catheters from patients. Mayo now requires training before anyone can remove these catheters, said Dr. Timothy Morgenthaler, Mayo's patient safety officer.

Most vexing for hospitals has been the prevention of severe falls. In 60 percent of last year's cases, the patient had been checked by nursing staffers within 30 minutes of the fall. Sometimes, the fall occurs in the presence of hospital staffers, said Dr. Penny Wheeler, chief medical officer for Allina Hospitals & Clinics.

"A significant number ... occur when someone is going to the bathroom," Wheeler said. "How do you balance patient privacy with safety?"

Hospital leaders are hoping for signs of progress from the Mille Lacs Health System, which is testing infrared motion sensors to detect patients' movements before falls occur.

Mayo's Morgenthaler said the plateau in reported events is misleading because more events now qualify as reportable. It's like the difference in clarity between regular and HD television, he said.

"You see all these little blemishes [watching HD] and wonder, 'How come people have gotten so much uglier?' The answer is, well, they haven't. We're just looking at them a lot more carefully."

Jeremy Olson • 612-673-7744

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