WILLMAR - After a patient died last year as the result of a fall, Appleton Area Health Services examined the event and all the circumstances surrounding it.
The hospital began implementing several changes. Bedside reporting and whiteboards are being introduced to give more opportunities for patients and families to communicate with staff and become more engaged in patient care, said Stacey Weinkauf, director of nursing.
Hourly rounds have been implemented to check on patients more frequently.
Losing a patient to a fatal fall was painful for the entire staff but it has led to more knowledge about why falls take place, how they might be prevented and how to make patient care safer, Weinkauf said. “It forces you to step back and take a look at all your processes.”
The Minnesota Department of Health released its annual Adverse Health Events report Thursday, outlining “never” events that happened at Minnesota hospitals this past year and strategies being put in place to improve patient safety.
Minnesota hospitals and surgical centers reported a total of 308 adverse events in 2013-14. These included 98 serious injuries and 13 deaths.
Two other area health facilities, besides Appleton, had reportable events during the time span covered by the report, from October 2013 to October 2014.
Meeker Memorial Hospital of Litchfield reported two adverse events: a fall resulting in serious injury and the irretrievable loss of an irreplaceable biological specimen, which resulted in neither death nor serious injury to the patient..
The Willmar Surgery Center reported two events: retention of a foreign object and the wrong surgery or invasive procedure. Neither caused death or serious injury.
The number of adverse health events was swelled this past year by the addition of four new “never” events: loss of a biological specimen, death or serious injury resulting from failure to follow up or communicate on test results, infant death or serious injury associated with labor and delivery in a low-risk pregnancy, and death or serious injury associated with the introduction of a metallic object into the MRI area.
The four new types of adverse events accounted for 31 incidents reported this past year to the state Health Department.
This is the 11th year the report has been issued, adding to a growing body of knowledge about system vulnerabilities, risk factors in patient care and best practices shown to make care safer.
“We have processes in place every day that help to prevent harm,” said Wendy Ulferts, chief nursing officer at Rice Memorial Hospital in Willmar.
Whenever an incident takes place, it’s identified as soon as possible and thoroughly evaluated to determine how Rice can improve its processes, she said.
This doesn’t only happen with incidents that rise to the level of being reportable to the state Health Department, she said. “We do it for smaller events as well. Every event is significant for a patient.”
In addition to this, the hospital tracks “good catches” - incidents that almost happened but were caught in time.
Rice had no reportable events last year but “it doesn’t mean we should be easing up our processes,” Ulferts said. “We have to continue to work just as hard to keep our organization safe and our patients safe and our staff safe.”
By reporting the most serious events and examining the circumstances that surround them, hospitals and surgical centers have been able to collectively learn so patient safety can be improved, say state health officials.
For example, the Health Department, the Minnesota Hospital Association and other partners tackled recommendations this past year on reducing the risk of falls among patients taking blood-thinning medications. Prompted by a rising level of violent attacks on hospital staff, a state work group also was formed to address violence prevention in the health care workplace.
Statewide projects in 2015 include the development of strategies for reducing lost or damaged biological specimens and identifying and implementing best practices for communicating test results.
The complexity of healthcare processes makes it challenging to move the needle significantly on patient safety. Although there was a decrease this past year in the number of sponges, gauze and surgical packing material left inside patients, there was an increase in small fragments, instruments or wires left behind after a procedure.
And after studying the six infant deaths or serious injuries reported this past year that occurred with a low-risk pregnancy, hospitals in most cases were unable to find a clear reason why these happened.
The report noted sustained improvement in some areas. The number of falls declined from the previous year and the number of wrong-site surgeries and procedures declined for the second year in a row. The number of deaths from adverse health events also was the lowest since 2011.
On the web:
http://www.health.state.mn.us/patientsafety/ae/
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