Minnesota hospitals on Wednesday reported 21 avoidable deaths and 178 serious injuries due to surgical errors or lapses in patient care, revealing the pressures of the pandemic and persistent staffing shortages.
The deaths in the 12 months ending last October were the highest in Minnesota's annual reporting since 2006. They included two deaths from medication errors, three that involved malfunctioning devices, and four in which crucial lab or test results weren't communicated in time to save patients.
The state reported a record 572 errors in hospitals and surgery centers when including those that didn't cause severe harm but often required corrective treatment or observation. The total was driven largely by 290 pressure ulcers (also called bed sores) that are getting harder to prevent as average patient ages trend higher and people need longer stays for complex care.
"The workforce shortage in hospitals results in the need to prioritize the critical care patients first, and there are fewer hands to assist with repositioning and those things that are basic practices that are going to prevent those pressure ulcers," said Rachel Jokela, director of Minnesota's adverse event reporting system.
Minnesota was the first in 2005 to publish the number of these events and the facilities at which they occurred. Wednesday's report spanned the delta and omicron waves of COVID-19 in late 2021 that filled hospitals and had health care leaders pleading with Minnesotans to prevent infections.
The errors disappointed health care leaders even though they represented a fraction of the more than 500,000 procedures and 5 million days of patient care last year.
"These are tragic, rare events and we are deeply sorry that these events occurred," said a statement from M Health Fairview, which reported six deaths at the University of Minnesota Medical Center, including three involving device misuse or malfunction.
Two occurred when staffing shortages due to COVID-19 forced the shuffle of critically ill patients into different units, where problems with monitoring equipment weren't immediately recognized, said Dr. Abraham Jacob, the health system's chief quality officer.
"Even if it was a five-minute delay, we're going to own that," he said, because the goal is to learn from these events. Jacob has organized a forum in November for state leaders to discuss how to maintain safety in future public health emergencies.
The state reported three surgeries or procedures on the wrong patients at United and Regions hospitals in St. Paul and Mercy Hospital in Coon Rapids. The events occurred despite widespread use of barcoded wristbands to verify patients' identities and surgical site marking to ensure the correct procedures.
Jokela said they tend to happen when the order of patients in surgery schedules gets disrupted or bedside procedures are conducted on the wrong patients in shared rooms.
"It's basic practices that just aren't happening, whether it's double-checking ID bands or things like that," she said. Hospitals often require two ID checks, such as looking at wristbands and asking patients their birthdates.
The pandemic accelerated an exodus of clinicians from hospitals, and the resulting shortage contributed to reportable errors — including four deaths of newborns in deliveries that otherwise lacked complications. Some of these deaths involved a delayed response to fetal heart rate alarms that indicated the need for emergency deliveries.
Large hospitals had the most adverse events, including 63 at Mayo Clinic and 60 at Hennepin Healthcare, but small hospitals reported them as well. Newborn deaths occurred at Riverwood Healthcare Center in Aitkin and Lakewood Health System in Staples.
The Legislature allocated $1.3 million over the next two years to study links between these events and nursing shortages. It also eliminated the requirement of an annual report after this year. The Minnesota Department of Health will still publish totals online of the 29 types of reportable events.
This year's report included the discharge of three newborns or other patients lacking decisionmaking capacity to the wrong people at the U, Hennepin Healthcare, and St. Luke's Hospital in Duluth.
Fourteen patients or workers at Minnesota hospitals were seriously injured by physical assaults, double the previous high of seven last year. The total matches with increases in workers' compensation claims and nurse reports of more incidents involving agitated patients or upset relatives.
Four deaths and six serious injuries were attributed to a lack of communication about test results.
"It's usually things like potassium levels, glucose levels, where the level from a blood test is critical," Jokela said. "That critical result is not shared with the correct people, whether it is the nurse at the bedside or the physician, to take action. Sometimes it's too late."
Each adverse event triggers an internal analysis by hospital leaders to determine its cause. Lessons are shared across hospitals to reduce errors statewide.
Regions reported four of Minnesota's 18 incidents in which the wrong surgeries or procedures were performed, and two of 36 incidents in which objects were left inside patients after procedures.
On Monday, Regions unveiled a new simulations center to help avoid these problems. Providers can use mannequins for practice with diagnostic decisions, surgical techniques and labor deliveries, and don virtual reality goggles to hone their skills on calming agitated patients.
Practice in lifelike conditions saves lives and reduces the stress that drives clinicians from hospitals, said Ryan Aga, director of simulation for HealthPartners, which operates Regions. "It's a psychologically safe environment where professionals can fail and, more importantly, learn from those failures before caring for actual patients."