Minnesota hospital errors revealed (01/20/05)

Minnesota hospitals performed surgery on the wrong body parts, gave the wrong medications or made other mistakes that endangered patients 99 times in a 15-month period starting in the summer of 2003, according to the first such report in the nation.

The report, released Wednesday by the Minnesota Health Department, said that 20 deaths were associated with hospital errors, including eight people who died after falls and four after medication errors.

Until now, these kinds of numbers were among the most closely guarded secrets in medicine. Now, Minnesota hospitals are required by law to report 27 kinds of mistakes or preventable accidents known as "never events," which experts say never should happen.

In all, 30 of 145 hospitals reported at least one "never" event between July 2003 and October 2004. Some of the most respected -- and largest -- hospitals were among those reporting the most errors in the first of what will be an annual report.

Fairview-University Medical Center, the state's premier teaching hospital at the University of Minnesota, had the largest number of reported errors.

Fairview reported 13 errors, including one associated with a patient's death, according to the report. Another Minneapolis hospital, Abbott Northwestern, came in second, with nine errors and two associated deaths.

The Mayo Clinic reported six errors at its two Rochester hospitals, including two deaths associated with medication errors and one operation on the wrong body part.

Hospital officials say the disclosures, while painful, are intended to help them learn from each other's mistakes and to improve patient safety. Already, they say, they have takensteps to reduce the chances these mistakes will happen again.

"I'm sure all of us will be sobered by the report," said Barbara Balik, executive vice president for safety and quality at Allina hospitals and clinics, which owns Abbott Northwestern. She said that health officials are starting to learn the lessons of the airline industry. "The way you improve safety is by reporting, learning and then fixing the problems."

More than half the reported mistakes occurred during surgery. Of those, 31 involved foreign objects, such as sponges and needles, that were left inside patients after surgery.

There also were 13 cases of operations on the wrong body part, a third involved spinal surgery, and 24 cases of bedsores, which can be dangerous if they become infected.

Most of the patient deaths were associated with falls, medication errors and faulty or misused medical devices.

St. Luke's Hospital in Duluth reported the most deaths: one patient each in four categories: a fall, a burn, a medication error and a problem with a device. Fairview Southdale Hospital in Edina had three deaths.

Hospital officials say the reports do not necessarily mean that the errors caused the deaths. Jo Ann Hoag, a nurse who co-chairs St. Luke's patient safety program, said hospitals were required to report any death "associated with" an error. The hospital took the broadest possible view. If the error and the death occurred during the same hospital stay, it was reported, she said.

"We didn't look at cause and effect," she said. "We're not trying to explain this away. We're trying to say how we interpreted the intent of the law."

State officials said there was some ambiguity in the rules, but that the intent was to report errors that contributed to patient deaths or disabilities. Statewide, four patients were left with serious disabilities, the report showed.

"This is a ground-breaking day for health care in Minnesota," said Dianne Mandernach, state health commissioner. "The first step is learning why these events occur and then fixing the system so it won't happen again."

The report contained no patient names or details, and hospitals would not discuss individual cases. "What we're here to talk about is what we're learning from these situations and not individual events," Hoag said.

A spokeswoman at Fairview Health Services said hospital officials regret the errors and have taken elaborate steps to ensure that they don't happen again. "I don't want to make any excuses for any of these numbers," said Alison Page, vice president for patient safety. "We're only focused on getting to zero on these numbers, and none of these events should occur."

The state's largest hospitals generally reported the highest numbers of mistakes. But they also treated many more patients than community hospitals, and their error rates were lower than some smaller hospitals.

The good news was that there were no incidents reported in such categories as discharging an infant to the wrong person, or death or disability from electric shock. Only one reported case involved a criminal event: a physical assault on a patient at Hennepin County Medical Center. The hospital did not provide details. Hospital officials acknowledged that people may be surprised by the number of reported mistakes. But they noted that state hospitals treat nearly 600,000 inpatients each year, in addition to 1.5 million emergency-room visits and 300,000 outpatient surgeries.

"By definition, these events are rare," said Bruce Rueben, president of the Minnesota Hospital Association. Yet, he added, "they are measurable. They are preventable. They should never happen."

Mandernach said hospitals are required to investigate each error, and come up with a corrective plan. "The real crux of this is what the facilities are going to do as a result of it," she said.

Hospital officials admit that they're nervous about how the report will affect their reputations. "It would be tragic if patients become increasingly concerned about the care that they [receive]," said Dr. Michael Osborn, a cardiologist at the Mayo Clinic who chairs its quality oversight committee. "I hope that what it will show our patients is that we're serious about evaluating these episodes and we're serious about preventing them."

The Minnesota Hospital Association pushed for the state law that set the reporting in motion in 2003.

Minnesota was the first state to adopt a list of 27 reportable events proposed by the National Quality Forum, based in Washington, D.C. Two others, New Jersey and Connecticut, have followed suit but have not released results yet. The list was inspired by a 1999 Institute of Medicine report that estimated that 44,000 to 98,000 people die each year from hospital errors.

One problem, experts say, is that some mistakes are so rare, hospitals may not realize the danger until the numbers are tallied statewide.

That's the purpose of this kind of report, said Dr. Kenneth Kizer, president of the National Quality Forum. "If you've got human beings involved, you're going to have errors," he said. "The two go together. If so, then let's design systems so you minimize those errors. Let's change the whole culture so we view these things as learning experiences."

The report can be found at www.minnesotahealthinfo.org or www.health.state.mn.us.

Staff writer David Phelps also contributed to this story. Maura Lerner is at mlerner@startribune.com.