Mishap-Related Deaths Rise At Minnesota Hospitals
Despite efforts to reduce the fallout from serious adverse events that occur in Minnesota's hospitals, the latest reporting from state regulators indicate the mortality rate from such mishaps are on the rise.
Altogether, there were 314 adverse events in Minnesota's hospitals and ambulatory surgical centers during the last fiscal year, which ended on Oct. 6, according to data compiled by the Adverse Health Care Events Reporting System, which is operated by the state Department of Health. That's about the same number as in 2011, but the number of deaths related to the incidents rose to 14 – compared to five in 2011. That's the highest number of deaths since 2008, when 18 reported.
“We are disappointed to see an increase in deaths and patient harm. Each of these events affects a patientand a family, and we take each one very seriously,” said Lawrence Massa, chief executive officer of the state's acute care lobby, the Minnesota Hospital Association.
In addition to the patient deaths, there were also 89 serious injuries associated with the adverse events – compared with 84 in 2011.
Pressure ulcers were the most common adverse event, with 130 reported, followed by falls (75), retained surgical objects (31), and wrong-sided surgery (27). Five other kinds of mishaps comprised the 51 other adverse events.
Minnesota's tracking system keeps tabs on 28 adverse events, including wrong-sided surgeries, retained surgical objects, burns related to medical procedures, avoidable embolism, suicides, or harm that befell a patient who wandered away from the care setting. In 2013, 75 hospitals and ambulatory surgical centers submitted reports, although more than 200 operate statewide.
Most of the deaths and injuries were related to a patient who fell while in a treatment setting – nine out of 10 were associated with falls. And in those incidents, 60% of patients had been seen by a caregiver 30 minutes prior to the fall. Despite the efforts to make sure that the patient was properly positioned or had their toilet needs attended, many still engaged in elopement – getting up on their own without needed care.
“This year's report shows that as a state we really need to redouble our efforts to reduce falls in hospitals,” said Minnesota Commissioner of Ed Ehlinger, M.D. “While falls in healthcare 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.”
Despite the increase in mortality rates associated with adverse events, the number of events associated with medical errors were in decline. Medication errors declined by 75%, retained surgical objects dipped 16%, and pressure ulcers were down by 8%. According to state officials, it was the first time since it began compiling adverse events nearly a decade ago that pressure ulcers have actually declined.
Under state law, a root cause analysis must be undertaken anytime an adverse event is reported. Data compiled by the state indicated that deviating from rules, policies and procedures caused 36% of all adverse events, followed by communication and physical environment issues, both comprising 26% of the root causes for the incident.
