A couple years back, when I was writing about Minnesota's system of reporting serious and preventable hospital errors, I was invited to an East Metro hospital to watch how doctors marked on their patients the sites of their operations. The doctors and patients then initialled the incision sites to show they both agreed they were correct.
This was billed as a major step forward. Site marking started after rare but shocking cases in which doctors performed operations on the wrong sides of the body or on the wrong anatomy. It took a while to get all of the doctors on the same page in terms of how to mark patients. Some marked an X on one side of a patient to indicate that was NOT the side of the operation. For other doctors, X marked the spot of the operation. (You can see how that might create confusion!)
But the process of site marking has evolved even since my visit to the hospital. And, as a result, one piece of information I included in today's story on adverse event reporting in Minnesota is behind the times.
Safety experts in Minnesota now advise doctors to mark and initial the operation sites -- and to have patients watching that process -- but they NO LONGER want the patients to initial the sites as well. (My story said that patient initials are still part of the process.)
"We do not want to have extra initials on (the patients)," said Kathleen Harder, PhD., the director of the University of Minnesota's Center for Design in Health. "That may lead the (surgical) team down the wrong path."
Harder is the guru behind many of Minnesota's hospital safety programs, including the "time out" processes that are used before surgeries to ensure that surgical teams are performing the right procedures on the right patients. More of these ongoing safety efforts are described in Minnesota's 2013 adverse event report, released Thursday.
Below is my count of the number of errors reported by Minnesota hospitals each year, and the number of deaths and disabilities associated with them. The number of disabilities shoots up in the 2009 report, because the state started counting disabling falls as well as fatal falls. The state also broadened the definition of a reportable pressure sore that year.
|REPORTING YEAR (events took place in prior 12 month period)||TOTAL||DEATHS||DISABILITIES|