The 2010 Adverse Events Report can be found online at

READ THE REPORT The 2010 Adverse Events Report can be found online at

Hospitals: Deaths, falls decrease but errors persist

  • Article by: MAURA LERNER
  • Star Tribune
  • January 14, 2010 - 12:00 AM

Minnesota hospitals reported a significant drop in the number of fatal mistakes last year and a dramatic reduction in fall-related injuries, according to the sixth annual report on hospital errors by the Minnesota Department of Health.

In all, four people died as a result of "adverse events" at Minnesota hospitals in the 12 months ending October 2009, compared to 18 the year before. That was the fewest deaths since the state began reporting the statistics in 2005.

This is also the first year that no hospital reported a fatal fall.

The report, released Thursday, tracks 28 types of mistakes or accidents -- known in the hospital industry as "never events" because they're never supposed to happen -- such as wrong-site surgeries, severe bedsores or dangerous medication errors.

Yet they did happen 301 times last year, according to the 2010 report, down slightly from 312 times the year before.

Health officials say the latest report shows they're making progress, especially in preventing dangerous falls, which dropped by 20 percent.

But they admit that other safety efforts have fallen short: Last year, Minnesota hospitals performed the wrong surgery, or operated on the wrong patient or wrong body part, 44 times.

Half of the surgical mistakes, it turns out, were not in operating rooms but in other settings, such as catheter labs and inpatient rooms, where many procedures now take place.

"We're certainly frustrated by some of the categories where we're not making progress," said Lawrence Massa, president of the Minnesota Hospital Association. But he said hospitals have made extraordinary efforts to improve patient safety, and "I do think they've made a difference."

The report provides a window into what can go wrong in a hospital or surgical center. Last year doctors left 38 "foreign objects" (often gauze sponges or needles) inside patients during surgery. Three patients attempted suicide while hospitalized (one succeeded); two others died from hypoglycemia, a dangerous drop in blood sugar levels; one healthy patient died from complications of surgery.

The biggest single "adverse event" category was bedsores, which can cause serious skin infections and accounted for 122 incidents, more than a third of the total last year.

Nearly 100 patients were seriously injured or disabled as a result of their hospital stays, including four from medication errors, one from a burn and 76 from falls.

But there were far fewer serious falls than the previous year, when 85 patients were injured and 10 died in falls, suggesting that prevention efforts are paying off, said Dr. Sanne Magnan, Minnesota's health commissioner.

"Given the results this year, I'm encouraged," she said. The problem, she said, often occurs when frail patients don't want to bother the staff and try to get up from bed by themselves.

Since 2007, hospitals throughout the state have joined in a campaign to prevent falls, identifying those patients most at risk and taking extra precautions.

At Methodist Hospital in St. Louis Park, for example, risky patients are given low beds that are only about 18 inches off the ground. If they do fall, "it's like rolling off your mattress onto the floor," said Dr. Tom Schmidt, chief of patient safety. Schmidt said Methodist started using the low beds, with safety mats beside them, about a year and a half ago. Since then, he said, the hospital has reduced falls by 15 percent, and cut fall-related injuries "by almost 50 percent."

It's not foolproof, though. In spite of its efforts, Methodist reported five patients injured in falls. "That's the frustration," Schmidt said.

That's equally true with surgical errors. For several years, Minnesota hospitals have been beefing up their safety rituals in operating rooms, to try to ensure that the right patient gets the right procedure and nothing gets left behind. But last year, the number of surgical "adverse events" crept up from 77 to 83.

In one case, surgeons implanted the wrong size artificial knee or hip, then had to go back in and replace it, said Schmidt. "You wonder how this stuff happens," he said. "It was a total breakdown in communication."

Massa, of the hospital association, says that can happen in spite of the best efforts. "We do a lot of double-checking patients, but it still happens," he said. "There's human error in this as well. We try to create systems that have many backups so it catches errors before something happens. We obviously haven't gotten that totally perfected."

As in past years, some of the biggest and busiest hospitals reported the largest number of "adverse events":

• 41 at the University of Minnesota Medical Center;

• 30 at the Mayo Clinic's St. Marys Hospital in Rochester;

• 24 at Hennepin County Medical Center,

• 22 at Methodist Hospital in St. Louis Park.

Hospital officials, though, say the report shouldn't be read as a score card on individual hospitals.

"The real question is, what are we learning from our own experience and what are we learning from each other's experience that's making care safer," said Schmidt, of Methodist Hospital.

Massa agrees. "We tell our members that just because you haven't had an event, don't let your guard down," he said. "This is something that requires constant vigilance."

Maura Lerner • 612-673-7384

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