While Mayo Clinic Health System in Mankato has seen more adverse health in events in 2012 than 2011 -- including one resulting in death -- officials say they’ve already implemented changes to ensure similar incidents don’t happen again.
Also, MCHS says its 2012 numbers show major improvements from the previous year in other areas, including leaving foreign objects behind following surgeries and medication errors.
The announcement is part of the annual Minnesota Department of Health report on adverse health events in hospitals and ambulatory surgical centers to report incidents that fall into one of 28 areas regarding patient care. This mandated reporting dates back to 2003.
Statewide, the total number of incidents has remained about the same, but several trends emerged this year. The number of patients reporting bed sores, for example, dropped 8 percent from the previous year. So has the number of retained foreign objects, which dropped 16 percent statewide. Medication errors dropped 75 percent, the lowest numbers ever reported for this annual survey.
The most serious adverse health event reported from a MCHS facility involved a patient fall that resulted in death.
MCHS is unable to divulge details about that fall but did say the incident prompted an immediate analysis of the situation and, after review, implementation of new safety measures.
Steve Campbell, a physician with Mayo Clinic Health System in Mankato, said hospital staff had “correctly identified” the patient as a low fall risk. But a review of the incident prompted MCHS to begin making a tool kit available that would help hospital staff ensure beyond their normal protocols that a patient won’t fall.
Since implementing the tool kits, Campbell said, there have been no falls.
Campbell also touted the hospital’s record on other matters, including its clean record in the category of retained foreign objects.
In early 2012 Mayo Clinic Health System in Mankato started using a bar code scanner to inventory all sponges used before and after a surgical procedure. Since implementation of the bar code scanner, there have been no retained foreign object incidents.
The other categories in which the Mankato hospital recorded adverse health events were pressure ulcers, also known as bed sores (2 incidents) and retained foreign object (one incident).
Campbell, when asked if he was happy with the results for 2012, was blunt: “No. Any number greater than zero is too many,” he said. However, he said he’s happy with the progress made at MCHS facilities in Mankato, New Prague and Fairmont.
Statewide, there were 314 incidents in 2012, a number that included 14 deaths (up from five the previous year) and 89 that resulted in serious injuries (up six from the previous year).
Incidents are reported to the state immediately, Campbell said. Soon after, an incident a team of medical professionals is assembled to investigate the incident and determine what happened. Campbell said that in most cases that process is completed within 30 days.
In the reporting period for the 2012 report -- which ran from Oct. 7, 2011 to Oct. 6, 2012 -- MCHS in Mankato performed 34,053 procedures and incurred 65,901 patient days.