Preventable errors have nearly doubled over the past decade in Minnesota hospitals, where staffing shortages and other pressures have left patients more vulnerable to disabling falls, assaults and surgical and laboratory mix-ups.
The 610 adverse events in the 12 months ending last October remain rare, considering that Minnesota hospitals perform roughly 567,000 surgeries and procedures each year. Still, health care leaders said they are troubled by the increase post-pandemic.
Sixteen patients died last year from reportable events, such as medication errors or device malfunctions, while another 222 suffered disabling injuries.
Hospitals might need to go “back to the basics” and recommit to longstanding safety practices, said Rachel Jokela, director of the Minnesota Department of Health’s adverse event surveillance system, which allows people to look up error totals by hospital.
“With anything ... we do all the time, it just becomes so automatic that you might drift a little bit. You might not be paying as close attention,” she said.
The reporting system was a national pioneer when it was started 20 years ago. Publicizing medical errors helped usher in changes at hospitals, such as marking in ink incision sites for surgeries to prevent operations on the wrong body parts. Hospitals also shared lessons to prevent others from making similar mistakes.
Reviews of recent adverse events show those safety efforts don’t always work. The state reported 25 wrong-site surgeries last year despite the site marking protocols. Sometimes, Jokela said, clinicians marked the operation sites from memory, without the required verbal verifications or the double-checking of written records.
Inattentive counting during surgeries also contributed to a record 42 incidents in which sponges and other items were left inside patients. Items in some cases were intentionally left in patients during their recoveries, but then hospitals forgot to remove them.