WILLMAR -- After a piece of a sizing cuff was accidentally left inside a patient during major surgery at Rice Memorial Hospital last year, a hospital team gathered to analyze how it happened and how to prevent similar incidents in the future.
The hospital has since adopted a different system of accounting for the equipment that's used during large surgical cases such as this one.
"It did result in us making some changes in the way we were doing things," said Maureen Ideker, associate administrator of care management and chief nursing officer at Rice.
The incident was among 301 "never" events reported by Minnesota hospitals and surgery centers during 2009. The annual report was released this week by the Minnesota Department of Health.
This is the sixth year that hospitals in Minnesota have been required to track and disclose significant adverse events ranging from wrong-site surgery to medication errors, in-hospital suicides and patient falls that result in death or disability.
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The number of serious incidents dropped slightly this past year, from 312 to 301. Four patients died last year from an adverse health event, the lowest number since reporting began. Another 94 adverse events led to serious disability.
The retained sizing cuff from surgery was the only "never" event reported last year by Rice Hospital. In 2008, the hospital had no incidents that met the reporting threshold.
Among area hospitals, Meeker Memorial Hospital in Litchfield last year reported one patient fall that resulted in disability. No other area hospital or surgery center had a reportable event in 2009.
Reporting errors has enabled hospitals across the state to learn from what goes wrong and figure out strategies to prevent harm to patients, said Ideker, who serves on a Minnesota Hospital Association committee to study and discuss patient safety strategies.
"It's helped to raise awareness," she said. "It's a big change. Before, it used to be very punitive. There wasn't any learning to it at all."
By reviewing the data from hospitals, state health officials have learned, for instance, that when a foreign object is accidentally left inside a patient, many times it's because of broken or separated device components, or involves sponges or gauze that were intended to be later removed.
This led to the release of two safety alerts last year, and a statewide campaign by the Minnesota Hospital Association to reduce the incidence of retained foreign objects.
"By having the shared learning across the state, it makes a big difference. We can learn faster and learn more," Ideker said.
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Another lesson from 2009: Many of the pressure ulcers that were reported developed while the patient was undergoing lengthy surgery, or were linked to the use of devices that pressed on or rubbed against the skin. Two advisory groups will be working this year on recommendations for preventing pressure ulcers in the operating room and safer use of devices.
The most significant improvement this past year was in the prevention of falls. The incidence of patient falls resulting in death or serious disability fell by 20 percent in 2009, and there were no fall-related fatalities reported last year by Minnesota hospitals.
State health officials believe this is because of a statewide initiative to reduce the risk of injury and death from falls during hospitalization. More than 90 percent of the hospitals participating in the Minnesota Hospital Association's "Safe From Falls" campaign have implemented best practices for preventing falls. For some of these best practices, such as establishing interdisciplinary teams and creating systems to alert staff that a patient is at risk of falling, the implementation rate is nearly 100 percent.
Although errors can't be completely eliminated, it's the goal to try to make them as infrequent as possible.
"There's always the potential for human error," Ideker said. "Can we ever have our processes standardized enough that we can correct for the potential for human error? Clearly the goal is to keep trying to get there... We are making some definite progress."
