Report is released on the medical mistakes in Minnesota hospitals

WILLMAR -- Rice Memorial Hospital and Granite Falls Municipal Hospital each reported one adverse event to a statewide database in 2005.

The two events were among 106 reportable errors -- including 12 deaths and nine serious disabilities -- that occurred last year in Minnesota hospitals and outpatient surgery centers.

The annual report was released Wednesday by the Minnesota Department of Health. This is the second year the list has been made public.

Sharing the information will help hospitals across the state learn from their mistakes and improve patient safety, health officials said.

"When we all share as a group and identify patterns and trends, we all benefit," said George Gerlach, administrator of the Granite Falls Hospital and a member of the Minnesota Hospital Association's patient safety committee.

"We can be safer than we are by looking at this as a process," he said. "The system has to work to ensure that patients are safe."

Minnesota's Adverse Health Event Reporting Law, which went into effect in 2003, requires hospitals to disclose whenever any of 27 serious preventable errors occurs. The list of "never" events ranges from wrong-site surgery to medical device malfunction.

This year's report covers adverse events that occurred between Oct. 7, 2004, and Oct. 6, 2005. For the first time, outpatient surgery centers also are included.

Rice Memorial Hospital reported one wrong-site surgery during the year covered by the report. The patient did not sustain any permanent injury or disability.

At Granite Falls Hospital, one serious medication error was reported; the patient was disabled as a result of the error.

Serious pressure ulcers were the most frequently reported event. The second most frequent was a foreign object left inside the patient after surgery.

About half of the wrong-site surgeries that were reported occurred during surgery involving the knees or the chest. Overall, adverse events make up a small fraction of hospital admissions and procedures. About 2.1 million Minnesotans are admitted to a hospital each year; another 450,000 undergo same-day surgery each year at a hospital or outpatient surgery center.

When errors occur, however, they're painful, Gerlach said. "It tears up everybody -- the family, the staff and everyone who has to deal with it. ... No one comes to work planning to make a mistake so when it happens, we feel really bad. Patients are real people. Families are real people."

Hospitals have 15 working days to report serious errors to a Web-based registry maintained by the Minnesota Hospital Association. They then have 60 days to analyze what went wrong and come up with a corrective action plan.

Gerlach said the analysis helped the Granite Falls Hospital identify weaknesses and potential for error in some of its systems.

"We've updated policies and procedures. We've put teams in place to address medication administration and policies," he said.

Down the road, the hospital plans to implement bar coding and computerized entry of drug orders, he said. Staff training also is being conducted.

Even before the hospital completed its analysis of the mistake, hospital officials met with the family of the patient who was injured to ensure they were kept informed, Gerlach said. "I think that's a very important part of the process."

Rice Memorial Hospital has changed some of its processes as a result of the wrong-site surgery error that took place, said Peggy Sietsema, associate administrator for patient safety and clinical resources at the city-owned hospital.

"We really did a very close look at analyzing all the systems involved and what went wrong," she said. "The safeguards we had in place didn't keep this from happening."

Hospital officials will continue to monitor the surgery sign-off process "to ensure the changes we put in place stay in place," she said.

State health officials say that the lessons learned can help all hospitals by highlighting error-prone practices and encouraging them to adopt strategies that prevent mistakes -- for instance, developing tracking systems to reduce the likelihood that a sponge will be left inside a patient during surgery, or eliminating the use of unsafe abbreviations that might lead to a medication error.

"For us it was a very helpful learning thing," Sietsema said. "Hospitals tend to be more alike than they're different. There are complex systems and there are errors and system failures."

This learning process can be especially important for small rural hospitals, where the patient volume often is lower and less diverse, Gerlach said. "By sharing I think we will get a lot farther," he said.

Patients and families should be part of the safety process as well, said Sietsema.

Rice Hospital has begun handing out patient brochures with safety tips, she said. The hospital encourages patients to speak up when they notice something that might be unsafe. Comments and suggestions also are invited in the patient satisfaction surveys the hospital sends out.

"We've really tried to engage patients and families in the process," Sietsema said. "I think people are much more in tune now with patient safety."