MINNEAPOLIS, January, 17, 2008 - Deaths from medical errors decreased by more than 50 percent, with a decrease in deaths related to falls accounting for much of the improvement, according to the adverse health events report released in January by the Minnesota Department of Health (MDH).

"It's encouraging that we're making headway," said MMA President James J. Dehen Jr., M.D. "It's also a testament to the impact that good quality reporting and tracking can have on the ability of providers to find and fix problems."

Between October 7, 2006, and October 6, 2007, there were 125 reportable errors and 13 deaths, according to the adverse health events report. Four were due to falls, three were the result of suicide, and five were related to a product or device, and one was related to care management. Another 10 people suffered a serious disability due to an error.

During the comparable 2004-2005 time period, the state saw 154 reportable errors, 24 deaths, and seven serious disabilities. During 2004-2005, about half of the deaths, 12, were due to falls.

Of the 197 facilities covered by the law, 42 or 21 percent reported adverse events during this reporting period: 38 hospitals and four surgical centers.

As in previous years, stage three or four pressure ulcers were the most commonly reported events, followed by retained foreign objects left in patients and wrong site surgeries.

Dehen, himself a surgeon, said "the fact that we've added more processes to minimize the chances of surgical errors from happening is real progress."

These three categories of events accounted for more than 75 percent of reported events. However, for the first time, the number of reported pressure ulcers and retained objects both decreased, with pressure ulcers down slightly and retained foreign objects dropping to their lowest level since reporting began.

Of the reports submitted during the reporting period, 17 percent resulted in no harm to patients, while 19 percent led to either death or serious disability. A majority of events, 62 percent, resulted in a need for additional treatment or monitoring, but not a longer stay in the hospital.

During 2007, the Minnesota Hospital Association implemented programs to try to reduce errors related to pressure ulcers, falls and retained objects after surgery.

Here are some strategies, according to the report, hospitals, have taken to prevent falls, pressure ulcers, and surgical errors.

Pressure ulcers

• Revising skin assessment documentation to make assessment easier and more accurate.
• Developing new decision-making algorithms to assist nursing staff in implementing appropriate interventions for at-risk patients.
• Purchasing special equipment to use for patients at risk for pressure ulcers.
• Increasing use of wound, ostomy, and continence nurses as consultants.
• Increasing the use of visual aids and pictures to assist nursing staff in correctly staging pressure ulcers and in communicating skin issues upon shift transfer.
• Establishing pressure ulcer prevention work group to review all cases and look for common causes.
• Providing additional training to staff on working with patients or family members who are reluctant to cooperate with skin care practices.

Preventing falls  

• Using high-visibility indicators of patient’s fall risk (stars, bands, colored slippers, etc)
• Implementing new fall risk assessment policies and standardized assessment tools
• Modifying standard order sets so that a patient’s fall risk status is consistently considered when ordering medications
• Developing post-fall intervention protocol with clear assignment of roles
• Implementing rounding at least every two hours to address patient’s toileting and other needs
• Providing additional staff training on best practices in fall risk assessment
• Posting fall prevention actions prominently

Preventing surgical events

• Conducting second time-out and site marking when patient is repositioned or marking isn’t visible
• Assigning one individual to be accountable for implementation of time-out.
• Developing scripting for pre-operative procedures and clarifying who is responsible for calling time-out
• Creating mandatory checklist for use during invasive procedures, including site marking
• Ensuring that all site marking materials are indelible and designed to be clearly visible on all skin types
• Improving labeling on equipment carts so that left/ right implants and/or implant sizes are clearer
• Replacing sponges with radio-opaque or tailed sponges
• Standardizing sponge counting processes across units and departments
• Increasing the use of x-rays in the operating room to identify the correct surgery site and/or to identify retained objects
• Expanding the list of objects to be counted after a surgery or invasive procedure
• Implementing visual inspection of all instruments before/after a procedure