Eleven people died and 118 were injured in Minnesota hospitals and surgery centers last year from medical errors deemed preventable, including three infants who died during what were supposed to be uncomplicated deliveries.
Incidents of patient harm were reported Friday by the Minnesota Department of Health in its 15th annual adverse event report, which seeks to motivate improvements in hospital safety through information-sharing and publicity.
The state reported 384 errors in the 12-month period that ended Oct. 6 last year, including 17 severe medication errors and 33 incidents in which irreplaceable biological specimens from patients were lost. That was an increase from 342 errors reported in the prior year, but state health and hospital officials said it represents progress and a unique culture developed over 15 years of reporting in Minnesota in which errors are openly acknowledged as part of a learning process.
“Honestly, an open transparent conversation on this kind of serious event is not what we would have had 15 years ago,” said Marie Dotseth, an assistant commissioner for the Minnesota Department of Health.
Errors involving surgeries on the wrong body parts, which can range from operations on the wrong side of the body to placement of anesthesia at the wrong level of the spine, declined from 37 two years ago to 24 last year. State health officials attributed that to a concerted effort to refocus doctors and caregivers to the “time out” process, by which they review all elements of a procedure — including verifying the patient’s name — before starting.
“It does seem silly when you’re in the clinic room and it’s just you, the nurse and the patient and you’ve already been talking about the procedure, and then you go through this whole list,” said Dr. Amy Brien, Mayo Clinic Health System’s patient safety officer for southwest Minnesota. “The patient has to be like, ‘Are you kidding me? You can see that my arm is broken!’ But it’s just so important to do.”
Mayo’s Mankato hospital was one of three last year to report incidents of procedures on the wrong patients. Brien said the incident involved an emergency procedure when the usual precautions were bypassed. Hutchinson Health also reported a wrong patient procedure, which occurred when there was a last-minute change in the scheduling of cataract surgeries and one patient received a lens implant meant for another.
The hospital has expanded the timeout process for cataract procedures to now require that two people verify that the lens implant is correctly matched to the patient.
Hospitals in Minnesota report 29 different types of errors deemed preventable and convene experts to analyze the causes of each one. But solutions in some cases have been challenging.
The state reported five incidents last year in which newborns died or were seriously injured in the course of routine deliveries. Health officials have struggled to identify the underlying causes or to share with other hospitals any lessons they can use.
Essentia Health’s Deer River hospital purchased new fetal monitoring equipment after the reportable death of a newborn last year, but nobody is certain that the equipment would have prevented the death, said Dr. Rajesh Prabhu, Essentia’s chief patient safety and quality officer.
Essentia officials investigated but couldn’t pinpoint the cause of the tragic death, he said. “Obviously it was unanticipated because it was planned to be a routine delivery,” he said.
The other infant deaths occurred at the Fairview Range hospital in Hibbing and Carris Health’s Rice Memorial Hospital in Willmar. Thirteen rural Minnesota hospitals have stopped performing scheduled baby deliveries in recent years due to insurance costs and low volumes that prevent doctors and nurses from keeping their skills sharp, but about half the reported fetal deaths in the past five years occurred in metro hospitals.
Training has been provided to hospitals statewide on fetal heartbeat monitoring that can indicate unexpected complications and when it is safer during labor to switch to cesarean section deliveries, said Dr. Rahul Koranne, chief medical officer for the Minnesota Hospital Association.
“We also focused quite a bit on early warning signs of distress in the moms such as increasing blood pressure or bleeding,” he said.
While the number of reported hospital errors has increased overall, Koranne said the rate of errors hasn’t changed over the past decade. The numerical increase is partly due to more surgeries and procedures being performed, and more hospital departments beyond surgery participating in the reporting process, he said. The complexity of hospitalized patients has increased 20 percent over the past decade as well, he added.
“We are not perfect, but we constantly try to get there,” he said.
Large hospitals continued to report the most events. Mayo Clinic in Rochester reported 41, including one severe injury to a patient due to a failure to forward or communicate test results, and the University of Minnesota Medical Center reported 40, including two patient injuries due to misused or malfunctioning medical devices.
Falls continued to cause the most reportable deaths — five last year — along with 71 injuries in Minnesota hospitals.
Essentia hospitals reported four falls that injured patients, but the system has shown progress, Prabhu said. One prevention effort has been to oblige nurses, doctors, assistants and even janitors to answer calls from patients in their rooms to see what they need.
“One of the things patients do,” he said, “is if you don’t answer their call light … they’ll try to do things themselves.”