The Free Press, Mankato, MN

January 23, 2014

Annual report: MCHS reported 4 adverse health events

Staff Writer Robb Murray
and The Associated Press

---- — 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.

At the Mankato hospital, Chief Medical Officer Steve Campbell said the two falls that occurred prompted the hospital to re-evaluate its policies on patient care. They instituted hourly nurses' rounds to be able to better anticipate patients' needs.

The sexual assault was a situation between two patients but still fell within the mandatory adverse health event reporting parameters. Campbell said he wasn't sure if the case resulted in criminal charges but part of the reporting protocols require that the allegation have some measure of legitimacy.

"We reviewed our patient care attendant policy," Campbell said, "and made changes that would lead to this not happening again."

Surgical sponges being left inside a patient's body have been cut down dramatically at the Mankato hospital now that it uses a scanner-based system to keep track of surgical supplies. The left-behind sponge in this report originated from a procedure in the hospital's Emergency Department.

Campbell said going from seven events last year to four this year is a good thing, but there is still room for improvement.

"Any number greater than zero is too big," Campbell said. But he said he was pleased to have reported no pressure-ulcer incidents, no wrong-site procedures, or other of the 29 possible areas of adverse health events.

In addition to the annual report, the state released a 10-year report that addresses the trends since the law went into effect.

The department said the 10-year lookback shows encouraging progress.

"The AHE law was a catalyst for patient safety throughout the state," the department's 10-year evaluation report said. "It has helped bring patient safety to the forefront, increases awareness, and led to focused patient safety activities."

Health Commissioner Ed Ehlinger called the preventable mistakes "a wicked problem" because their causes are complex and reducing them requires aggressive efforts. But he said the reporting requirements have helped change old expectations that errors were just part of the price of doing business.

"We've really been able to bend the curve and start to reduce the number of deaths and the number of disabilities that have occurred in hospitals," Ehlinger said. "And our hospitals are safer than they were 10 years ago. They're safer because the hospitals have really taken on safety as part of their culture, from the top down, from the head person to the people on the floors."