‘Adverse events’ claim 2 at SMDC

• SMDC

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While the number of patient deaths in Minnesota hospitals as a result of mistakes or accidents fell dramatically last year, two of the four that did occur happened at Duluth’s SMDC Health System.

In the sixth annual report of “adverse health events” released by the Minnesota Department of Health today, SMDC also saw a patient given the wrong medicine resulting in serious disability, a woman inseminated with the wrong sperm, serious falls and a patient-against-patient sexual assault in the mental health unit. In a knee replacement, surgery on the wrong leg was caught in time, but not before the wrong leg was given regional anesthesia.

In all, four events were at St. Mary’s Medical Center and six at SMDC Medical Center (formerly Miller-Dwan Medical Center). SMDC Medical Center’s tally was the most reported by a Northland hospital.

Five were not preventable, SMDC spokeswoman Beth Johnson said. “There was nothing we could have done differently,” she said.

That included the deaths of a diabetic patient from hypoglycemia at St. Mary’s Medical Center and one seemingly healthy patient who died prior to surgery at SMDC Medical Center. In the first case, a hospitalized patient chose to use her own insulin pump which malfunctioned; in the second, a patient had a fatal reaction to anesthesia that couldn’t have been determined ahead of time, SMDC officials say.

“We deeply regret any time a patient dies in one of our hospitals,” said Dr. Jeffrey Lyon, SMDC’s patient safety officer. “Our hearts go out to the families of the people involved. These are the things that spur us the most to make improvements so it doesn’t happen in the future.”

Several incidents in one year doesn’t mean a hospital is bad, says Diane Rydrych, a state Health Department spokeswoman who wrote the report. Sixty-two of

200 hospitals and surgical centers reported a total of 301 adverse events from October 2008 to October 2009; 83 occurred during surgery. Such incidents must be reported to the state.

“What’s important is they’re finding them, they’re reporting them,” Rydrych said. “They’re shining a light on what’s happening in their facility. And they’re learning from them to make sure they’re not happening again in the future.”

At SMDC Medical Center, the case of a woman inseminated with the wrong anonymous sperm has led to a better system of storage to prevent a reoccurrence, said Lyon, who noted that the woman became pregnant but miscarried before she learned of the mistake. It was the first time a wrong sperm/or egg incident was reported statewide since the category was added in 2007.

“Our first goal is to find out what happened, why and what can be done to prevent similar events in the future,” he said.

Meanwhile, St. Luke’s Hospital in Duluth fared better with no deaths. It tallied three patient falls and one patient developing a pressure ulcer. The state categorizes the falls as resulting in serious disability, but John Strange, St. Luke’s president/CEO, says they’re all doing well.

“Every time there’s an issue with a patient, we look at it seriously,” he said. “We continue to look at equipment, at how we transport patients. We constantly review our procedures.”

Rydrych sees this year’s report, showing fewer incidents resulting in death or serious harm to patients, as encouraging. Among the findings: