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Little change seen by state in reportable patient harm at hospitals

WILLMAR -- Minnesota hospitals saw little change last year in the number of adverse events reported to the state Health Department.

There were 305 "never" events that met the mandatory reporting threshold, according to an annual report being released today by the state Department of Health. The number is a slight increase from the 301 adverse events reported in 2009.

Ten patients died and 97 suffered serious injuries.

The list of "never" events ranges from surgery on the wrong patient or wrong body part to medication errors, patient falls and serious pressure ulcers.

State health officials said Wednesday that they're renewing their call for health care providers to make patient safety a top priority.

"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 policy division of the Minnesota Department of Health.

As demands and workloads grow at hospitals, "we're concerned that many health care leaders may not be fully engaged in making changes that will prevent harm to patients," Rydrych said.

Sixty-two facilities -- 60 hospitals and two surgery centers -- reported adverse events in 2010. The report covers the period from Oct. 7, 2009, to Oct. 6, 2010.

Three area hospitals were among those where a "never" event took place last year.

Chippewa County-Montevideo Hospital reported one serious pressure ulcer and one fall. The fall resulted in serious disability to the patient.

Meeker Memorial Hospital in Litchfield had one report of a patient fall that caused serious disability.

RC Hospital and Clinics in Olivia reported a wrong-site surgery resulting in no lasting harm to the patient.

There were no reportable adverse events last year at Rice Memorial Hospital or the Willmar Surgery Center, or at hospitals in Appleton, Benson, Glenwood, Granite Falls and Paynesville.

Minnesota has been collecting data on harm to patients since 2005. The information has helped health leaders identify processes and practices that are especially error-prone and design safer ways of caring for patients.

One of the lessons learned in 2010, for instance, was that many pressure ulcers are associated with friction from medical devices such as tubing or splints. In response, a Minnesota Hospital Association advisory committee developed recommendations for preventing these types of pressure sores.

Because the surgical site marking was not confirmed in one-third of wrong-site surgery cases, the Health Department and Minnesota Hospital Association issued a safety alert last year, reminding facilities to take this step and providing guidelines for implementing it.

Rydrych and Dr. James Reinertsen, a national patient safety expert with The Reinertsen Group, called on hospital boards and chief executives to keep their focus on eliminating preventable harm to patients.

Among their suggestions: Telling patient stories of preventable harm at every board meeting, training board members in patient safety, and holding physicians and other providers accountable for using best practices and being engaged in patient safety efforts.

Anne Polta

Anne Polta covers health care, business/economic development and general assignment. Her HealthBeat blog can be found at Follow her on Twitter at @AnnePolta.

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