Hospitals make progress in patient safety, reduction of adverse events
WILLMAR — Minnesota hospitals are making progress in reducing the incidence of serious events that result in patient harm.
Hospitals have seen a decline over the past decade in the overall number of reportable adverse events such as wrong-site procedures, severe pressure ulcers, falls and serious medication errors, state health officials said.
There’s also been a decline in the number of patient deaths and serious, permanent injury resulting from medical error.
From year to year, however, progress has been mixed. Although hospitals had 258 reportable events in 2013, an 18 percent decline from the year before, the number of deaths was virtually unchanged — 15 in 2013 compared to 14 in 2012.
Even so, the focus on identifying and analyzing when things go wrong is an indication that the push for safer care has “helped to shine light on what was often a hidden problem,” said Dr. Ed Ehlinger, Minnesota Commissioner of Health.
“We learn so much from what other hospitals have reported and what they’re doing to be safer,” said Wendy Ulferts, chief nursing officer at Rice Memorial Hospital in Willmar. “The data gathering really is powerful.”
Four area hospitals had adverse events in 2013 that met the criteria for mandated reporting. The reporting period is for October 2012 to October 2013.
During that time span, Glacial Ridge Hospital in Glenwood reported one fall resulting in serious disability.
Meeker Memorial Hospital in Litchfield reported one fall that resulted in death.
Redwood Area Hospital in Redwood Falls reported one severe pressure ulcer that did not result either in death or disability.
Rice Memorial Hospital in Willmar reported one fall resulting in death and one wrong-site procedure resulting in neither death nor disability. In both cases, a root cause analysis was carried out to determine what happened, Ulferts said.
“We’re very much making sure we’re complying with all of the reporting requirements,” she said. “Both these events needed to be reported so we could learn from them.”
The wrong-site procedure involved a pain block administered to the wrong side of the body, she said. The fall-related death involved a patient who fell, sustained a head injury and died two days later.
Overall, falls were the most common adverse event leading to patient death in 2013, according to the state Health Department. Ten patients died from fall-related injuries incurred in Minnesota hospitals last year.
Last May the Health Department and the Minnesota Hospital Association issued a safety alert on better identification of risk factors leading to falls, spurring hospitals to adopt this as one of their best practices. Falls remain one of the most difficult hazards to eliminate, however, despite progress in other areas such as reductions in the incidence of wrong-site procedures and foreign objects left inside patients after surgery.
“Falls are still an area that’s very challenging for hospitals to try and address. It will continue to be something we work on,” Ulferts said.
State health officials said that 10 years of reporting and data collection on adverse events have led to greater knowledge about how and why errors happen. Before Minnesota’s reporting law went into effect, there was no statewide system for tracking the number and severity of adverse events at hospitals and surgery centers — and most states still do not require hospitals to report serious errors.
By reporting and analyzing wrong-site procedures, for instance, state leaders in patient safety have been able to identify key risk factors and develop recommended best practices such as having the surgeon mark the site before the procedure and holding a final time-out before going ahead with the procedure.
The 10-year evaluation of the effectiveness of the adverse event reporting law confirms that it’s helping hospitals learn, share their findings and continually improve safety and quality of care, said Lawrence Massa, president and chief executive of the Minnesota Hospital Association.
“When events happen and safety alerts and best practices are issued, Minnesota hospitals respond immediately to implement new patient safety practices,” he said.
“Never” events remain rare, representing a small fraction of the 2.6 million surgeries and procedures performed at Minnesota hospitals and surgery centers last year. But they pose the greatest risk to patients of harm or death.
In the 10 years since Minnesota’s reporting mandate went into effect, 80 percent of the state’s 117 hospitals and surgery centers have reported at least one adverse event.