The Free Press, Mankato, MN

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January 23, 2014

Annual report: MCHS reported 4 adverse health events

MANKATO — Mayo Clinic Health System in Mankato recorded four so-called "adverse health events" in the most recent state-mandated reporting period — three fewer than the year before.

Of the four, two involved patient falls and resulted in the hospital making changes to how frequently nurses check on patients. One incident involved a small sponge being left behind inside a patient after a medical procedure. And the last was a patient-on-patient sexual assault and did not involve staff.

For 10 years state law has required hospitals and ambulatory surgery centers to report 29 types of incidents, including bed sores, falls, foreign objects left inside a patient after surgery, surgery on the wrong body part, medication errors and suicides. The law also requires studying how the mistakes happened.

After 10 years, trends have emerged statewide that show deaths and other harm to patients from preventable errors such as falls and surgical mistakes are declining.

But in the area of falls — the category in which two of the Mankato hospital's reportable incidents occurred — progress has been slower.

Statewide deaths from preventable errors declined from a high of 25 in 2006 to a low of five in 2011, according to the report. But the number bounced back up to 14 in 2012 and to 15 in the 2013 reporting year, which ran from October 2012 to October 2013. Ten of those deaths were related to falls.

The annual report said such falls happened despite significant efforts by health care facilities, as well as a safety alert for preventing falls that the health department and Minnesota Hospital Association issued last May.

Total adverse events reported in 2013 were 258, down 18 percent from 2012, driven mostly by a 35 percent decline in pressure ulcers, also known as bed sores. Surgical errors, including wrong-site operations and objects left in patients, fell from a high of 89 in 2011 to 61 in 2013.

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