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Medical center reports burn incident

For the first time in three years, the Red Wing medical center had a reportable "adverse health event" as defined by the Minnesota Department of Health.

A patient suffered burns in the operating room.

"This was not a fire. It was a thermal injury related to equipment. We have since made changes to equipment," Dr. Jack Alexander said.

Alexander, who also is the chief medical officer for Mayo Clinic Health System in Lake City and Cannon Falls, confirmed that there were no reportable events at those hospitals.

The Minnesota Department of Health's annual report released Jan. 31 covers October 2011 to October 2012. The department found that the number of adverse events stayed about the same as in the previous 12 months, with the state averaging 26.2 a month or 12.1 per 100,000 patient days.

But more patients died: 14 in 2012 compared to five in 2011. The number of serious injuries rose from 84 to 89.

Most of the deaths and serious injuries were related to serious falls, Commissioner of Health Dr. Ed Ehlinger said in a press release.

"We really need to redouble our efforts to reduce falls in hospitals," Ehlinger said. "While falls in health care settings can be very difficult to prevent, we also need to look at all opportunities to prevent injury when falls do occur, by focusing interventions on each patient's specific risk factors."

Alexander said this is a prime example of how health care professionals can use the report to improve patient safety through comparing numerous reports involving similar problems.

The 2012 report, he noted, found that the majority of serious falls involved patients who had received fall-risk assessments. In fact, 60 percent had declined assistance from a staff member 30 minutes prior to falling while going to or from the bathroom.

The report tells providers they need to increase staff awareness but also better educate families and patients themselves who are older, post-surgical or on blood-thinning medications, he said.

The report also helps people in other facilities learn from those who have unusual, rare or seemingly random adverse health events.

Surgical teams know the risk of fire is high in the operating room, for instance, because oxygen, cauterizing tools and cleaning solutions are all present. While Mayo Clinic Health System in Red Wing learned and made changes after thermal equipment burned a patient, other hospitals can learn the same lesson through the report.

"If you just relied on your own internal information to make improvements, you probably would not be able to have a broader impact," Alexander said.

"Each year we get another small step forward," Alexander said. "The most important thing is this whole culture of safety. ... Each one of these events has a patient behind it. These are people we are talking about, and that has a big impact."

Ninth report indicates improvements

This is the ninth year Minnesota Department of Health has produced the adverse health events report. The 2012 report found hospitals and surgical centers improved in several key areas:

• The number of patients who developed bedsores declined by 8 percent -- first decline of this magnitude in the nine years of reporting. This year's total of 130 is down from a high of 141 last year.

• The incidents of foreign objects being left in patients declined by 16 percent. This is the first decline in this category in five years.

• Medication errors dropped by 75 percent from the previous year and were at the lowest level in all years of reporting.

Anne Jacobson

Anne Jacobson has been editor of the Republican Eagle since December 2003. 

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