Adverse health events remain flat but deaths, serious injuries in 2012 increase
WILLMAR — Minnesota saw little change last year in the overall number of adverse events reported by hospitals and surgery centers.
But there was a rise in deaths and serious injuries, most of them related to falls.
The annual report is being released today by the Minnesota Department of Health. It includes 14 patient deaths and 89 serious injuries due to “never” events. In 2011 there were five deaths and 84 serious injuries.
Three local hospitals experienced reportable adverse events last year, all of them involving patients who fell and suffered serious or disabling injury. Meeker Memorial Hospital in Litchfield reported two falls, and RC Hospital and Clinics in Olivia and Swift County-Benson Hospital each reported one.
The state Health Department tracks 28 different types of adverse events, from wrong-site surgeries and serious medication errors to falls, pressure ulcers and patient suicides. All are considered preventable “never” events which should rarely or never happen to patients.
Hospitals work hard to avoid adverse events, said Wendy Ulferts, chief nursing officer at Rice Memorial Hospital in Willmar.
But patient safety is challenging and complex, and the annual report points to how much effort it takes to reduce serious events such as falls, she said. “Even with a tremendous amount of work, you can have an event happen.”
Health officials say one of the keys is identifying all the factors surrounding an adverse event, analyzing them and learning from the process so that systems and practices can constantly be improved to increase safety.
When a patient at Swift County-Benson Hospital was seriously injured last year in a fall, it was promptly reported to hospital leaders who conducted a root cause analysis within the week, said Holly Rodahl, the hospital’s patient safety coordinator and risk manager.
Hospital staff also worked with Stratis Health, the Medicare Quality Improvement Organization for Minnesota, to carry out the root cause analysis and complete the formal report to the Minnesota Department of Health.
“We took that process through our quality process at the hospital,” Rodahl said. “We reported it to the medical staff and the board of directors.”
It was a valuable experience for everyone, especially for the depth of information that was learned, she said. “The biggest problem is people always want to start with the first cause and not always dig deeper. … It’s a complex process.”
Minnesota Department of Health officials said hospitals did better in 2012 at identifying patients at risk for falling and checking on them often. But they said there is still work to be done in creating individual prevention plans for at-risk patients and communicating their risk of falling to every member of the care team.
Patient and family awareness also is important, say patient safety leaders.
Patients at risk of falling might have a bed alarm that sends a signal to the staff if they try to get out of bed unassisted, Rodahl said. Or they might need the bed rails to be elevated, or instructions to call someone on the staff instead of getting up on their own.
Understanding the need for these measures — and asking when they have questions — can help keep patients safer, said Rodahl. “The more they’re asking, the more everybody is aware of it.”
Health officials found that in nearly 60 percent of the falls reported last year, someone on the staff had checked on the patient within the previous 30 minutes but the patient then got out of bed unassisted.
The Minnesota Department of Health and Minnesota Hospital Association have been taking an evidence-based approach to preventing harm, focusing on strategies that are backed up by data and looking at broader issues such as work flow and organizational culture.
In 2013, the Health Department and its partners will continue to focus on preventing falls. They also will provide more staff training on preventing patient suicides and will undertake an initiative to prevent the retention of fragmented or broken items during surgery and other invasive procedures.
Rice Hospital works on multiple safety initiatives each year, Ulferts said. “We work on planning each year where our priorities need to go. … Our overall culture of safety in health care is much improved, especially over the last 10 years.”
The state’s requirement to report the most serious adverse events has resulted in substantially more awareness, Rodahl said. “It’s brought the importance of patient safety more to the forefront and especially to administration, so that the safety comes from the top and goes through all departments. When administrators are aware and supportive, your outcomes are more successful.”