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Medical mistakes decline statewide

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news Red Wing, 55066
Red Wing Minnesota 2760 North Service Drive / P.O. Box 15 55066

A new study from the Minnesota Department of Health shows a decrease in the number of patients accidentally harmed in hospitals over the past decade, but health officials say there still is work to be done.

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The MDH began requiring hospitals to report errors — referred to collectively as adverse health events — 10 years ago.

The reporting system has raised awareness of medical mistakes around the state, leading to “better outcomes, faster responses and better practices,” Commissioner of Health Dr. Ed Ehlinger said in a statement.

The shared data already has been used to help craft policies to benefit patients locally, said Dr. Jack Alexander, chief medical officer for Mayo Clinic Health System in Red Wing, Cannon Falls and Lake City.

“We do take learnings from other parts of the state,” Alexander said.

Among the recent changes for Mayo Clinic Health System was development of a “universal protocol” to ensure invasive procedures are performed on the correct patient, he said.

Because the standards are uniform at all facilities, Alexander said doctors won’t have to adjust when traveling between sites.

He added that a main focus moving forward will be preventing falls, including changes to risk assessment for patients.

Of the 15 adverse health events resulting in death statewide last year, 10 were due to falls, according to the MDH.

“Our nursing staff is very tuned in to that,” Alexander said.

The MDH reporting system includes data on 28 types of preventable errors, such as wrong-site surgeries, pressure ulcers, falls and medication mistakes.

A broadening of reporting standards in 2007 limits some direct comparisons, but the MDH says its 10-year evaluation shows a downward trend in both the frequency and severity of mistakes.

There were 258 errors reported to the MDH between October 2012 and October 2013, an 18 percent decrease from the previous years’ numbers and the first time events dropped below 300 since 2007.

The MDH credits the reduction to a 35 percent decline in pressure ulcers.

The number of deaths attributed to adverse health events fluctuated over the decade, but reached a low of five in 2011 from 25 in 2006, the MDH added. The number of mistakes leading to serious disabilities also saw an overall decrease since 2008.

The MDH said its evaluation shows that medical errors are relatively uncommon, pointing to 2012 data showing around 300 adverse health events out of more than 2 million procedures conducted statewide that year.

But that rarity also makes the issue difficult to address, Alexander said, adding that further reducing mistakes will require staff to be “100 percent attentive to correct processes.”

Although it may be impossible, the ultimate goal is to eliminate preventable errors entirely, he said.

“Any time there’s an (adverse health) event is bad,” Alexander said. “They’re not a number, they’re a patient.”

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