Adverse event deaths and disabilities down in 2011
[MMA News Now, January 18, 2012] The number of errors causing serious injury or death to a patient decreased from 107 in 2010 to 89 in 2011, despite an increase in the number of reported adverse events.
This is the lowest level of serious harm since 2007. Minnesota was the first state to track and publically report adverse events that should never happen in hospitals in 2003. In 2011, five patient deaths were reported -- three from falls, one from a medication error and one from a fatal air embolism.
| ROOT CAUSES/CONTRIBUTING FACTORS*
Communication 35%
Rules/Policies/Procedures 34%
Environment/Equipment 25%
Training 20%
Barriers 6%
Fatigue/Scheduling 0% | The total number of reportable adverse events in Minnesota hospitals, ambulatory surgical centers and community behavioral health hospitals increased from 305 in 2010 to 316 reported by 61 hospitals in 2011, according to a report released today by the Minnesota Department of Health (MDH).
Nearly all of the increase can be attributed to increases in two categories: pressure ulcers and wrong procedures.
Wrong procedures and wrong-site surgery
There was also a notable increase in the number of wrong procedures in 2012. Minnesota hospitals reported 26 incidents last year in which doctors performed the wrong procedures on patients -- including 10 cases involving the wrong replacement joints, breast implants or cataract lenses, according to the Star Tribune. None of the wrong-procedure cases resulted in severe disability or death.
The figure is the highest in eight years of self-reporting by Minnesota hospitals. Officials cited many reasons for the mistakes including incorrect orders to inventories that make it easy to grab the wrong joint implants for orthopedic procedures.
Efforts have paid off in some areas. Surgeries on the wrong body part fell from 31 in 2010 to 24 in 2011, and this year there were on reported cases of objects left behind during various procedures involving women in childbirth, thanks to new systems for counting sponges in obstetrics.
The MMA has been a supporter of The Minnesota Time Out Campaign, launched in June, to eliminate wrong-site, wrong-procedure, and wrong patient events in three years.
The number of serious falls fell to 71, a decrease of 14 percent from 2010 and a decrease of nearly 30 percent from a high of 95 serious falls three years ago.
“One of the most crucial things we have learned from the adverse health event reporting system over the last eight years is that just telling staff to ‘remember to do the right thing’ is not enough,” said Diane Rydrych, director of MDH Health Policy Division. “To truly change practice, providers need to adopt solutions involving modifications in workflow or workspaces, staff roles, technology, team dynamics and organizational culture. But to do this successfully, leadership needs to be fully engaged.”
According to Rydrych, one promising new avenue for strengthening this work is the Minnesota Alliance for Patient Safety’s (MAPS) Roadmap to a Safe Culture, which will begin in early 2012. The MMA is a founding member of MAPS.
Click here to read the complete report, which highlights successful efforts among Minnesota providers to reduce errors.
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