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State report reveals slight increase in medical mistakes

Mistakes and preventable problems led to the death of one patient and numerous complications in others at Northland hospitals in 2010, according to a report released today by the Minnesota Department of Health.

Statewide, the number of serious mistakes and preventable problems at Minnesota hospitals remained about the same in 2010 as in 2009. The report shows 305 "reportable events" at 60 Minnesota hospitals and outpatient clinics from October 2009 to October 2010, up slightly from 301 events during the same period the year before.

Ten deaths were reported statewide, up from four deaths last year. They included the death of one patient who fell at Essentia Health St. Mary's Medical Center in Duluth, the only death from a hospital mistake in Northeastern Minnesota during the reporting period.

In the previous year, two of the four statewide deaths occurred at St. Mary's, from patient falls.

It's the seventh year that Minnesota has required about 200 hospitals and outpatient clinics in the state to keep track of and report 28 different categories of mistakes and problems that led to serious patient problems or deaths -- the most common being falls, pressure sores and foreign objects left in patients after surgery.

The death at St. Mary's was of a frail, elderly woman who asked to be left alone after being helped to the toilet, said Dr. Jeffrey Lyon, patient safety officer for the hospital. The patient then stood up before staff, just a few feet away, could help, he said.

"She ended up dying from a hemorrhage caused by the fall," Lyon said. "Patients at high risk of falling are identified when they enter the hospital with a wristband and a sign in their room, and they are given special instructions on not trying to stand on their own. ... But some people just want to be independent and try to get up anyhow."

Lyon said internal hospital investigations found five of six major falls in 2010 probably could not have been prevented by staff, with procedures fully followed, "including one person who fell while being assisted by three staff, one of which was a physical therapist."

St. Mary's also reported: two other falls that led to serious disabilities; two foreign objects left in a patient; a procedure performed on the wrong body part; and two pressure ulcers, or sores, none of which caused any serious disability. The eight incidents occurred among almost 108,000 patient days and more than 75,000 surgeries and procedures.

Other events reported in Northeastern Minnesota included two pressure sores and a fall at St. Luke's hospital in Duluth, leading to one serious disability; three falls leading to three serious disabilities at Essentia Health Duluth, formerly Miller Dwan; one surgery performed on the wrong body part at Cloquet Community Memorial Hospital, leading to no serious disability; one surgery performed on the wrong body part at Bigfork Valley Hospital in Bigfork, leading to no serious disability; one foreign object left in a patient at Rainy Lake Medical Center in International Falls; and one fall and one wrong surgery performed leading to one serious disability at Fairview University Medical Center-Mesabi in Hibbing.

Hospital mistakes statewide the past two years are down about 20 percent, on average, from previous years and show a marked effort by hospital administrators and staff to reduce preventable problems since the reporting program began in 2004, state officials said.

But officials also called on hospitals to do better.

"While these events are still exceedingly rare, we must never lose sight of the fact that each adverse event has an impact on a patient and their family, and that most are preventable," said Diane Rydrych, assistant director of the health department's policy division, in announcing the report.

One hospital safety expert said hospital boards of directors must become more engaged in safety measures so that safety remains a priority as policy is set -- including budget, technology updates and staffing levels.

"Minnesota is doing good work, but it's not enough yet," Dr. James Reinertsen, a national patient safety expert who heads the Reinertsen Group health quality consulting company, told the News Tribune. "You need hospital boards that don't tolerate lax following of safety rules. Boards have to make it easy for doctors and nurses to follow the ideas we have out there. And then they need to send a strong signal that they must follow those procedures, no exceptions.''

Reinertsen said hospital boards should not tolerate doctors and staff who are persistent rulebreakers. He also suggests that hospitals publicize their safety goals and performance. And he said the state should begin to track more kinds of hospital mistakes, such as infections.

"When hospitals share reports with the public, their performance tends to improve,'' said Reinertsen, formerly CEO of the Twin Cities-based Park-Nicollet medical system.

Reinertsen also recommends telling patient stories of preventable harm at every board meeting; training hospital board members on patient safety; and requiring board members to participate in leadership rounds or other activities that put them in contact with front-line staff and patients.

Lyon said much of that

already is happening at St. Mary's.

"You can't engage any effort, really, unless top management and the board are behind it. And we've had that here," Lyon said. "We don't keep score on these like a sporting event. These are real people and our goal (for mistakes and accidents) is zero. Our goal is each patient's safety."