Report: Preventable deaths and injuries rose in Minnesota hospitals in 2012

Serious injuries and deaths from preventable mistakes increased in Minnesota’s hospitals last year, with falls largely to blame.

In its annual report on what it calls “adverse health events,” released today, the Minnesota Department of Health reported 14 deaths during the last reporting year — from Oct. 7, 2011, to Oct. 6, 2012. That was up from five the year before. The number of serious injuries also was up slightly, from 84 to 89.

Two of the deaths occurred in Northland hospitals, both attributed to falls. They occurred at Essentia Health-St. Mary’s Medical Center and at Virginia Regional Medical Center, which is now Essentia Health-Virginia.

The report also cited nine serious injuries at Northland hospitals: three at St. Luke’s, one at Cook Hospital, two at Essentia Health-St. Mary’s Medical Center and three at Essentia Health-Duluth. All were attributed to falls.

The previous year’s report showed one death at a Northland hospital and eight serious injuries.

The number of adverse events is small compared with the number of days patients spend in hospitals. For example, the total number of incidents reported at Essentia Health-St. Mary’s Medical Center was five, compared with the 107,797 days patients spent in the hospital.

Overall, the state has an average of 26.2 adverse events per month, or a rate of 12.1 per 100,000 patient days, the Health Department said in a news release.

But Dr. Ed Ehlinger, the state’s health commissioner, said there’s room for improvement.

“We’ve had six falls that led to deaths (statewide),” he said in a telephone interview. “We need to redouble our efforts to identify what’s behind those falls and what we can do to prevent deaths from occurring when falls happen.”

Officials at Northland hospitals say they’re working to do just that. For example, Essentia Health is rolling out “purposeful rounding,” in which patients are visited at least once an hour with a focus on preventing falls, said Dr. Jeff Lyon, Essentia’s patient safety director.

“In some cases, (we’re) not asking people, ‘Do you need to use the bathroom?’ but saying, ‘You know it’s been three hours, I’m going to help you to the bathroom now,’ ” Lyon said. “Because a lot of our Scandinavian patients don’t ask for that.”

St. Luke’s knows about that type of patient, said Dr. Gary Peterson, the hospital’s medical director.

“We have a lot of patients who are stoic and self-reliant, and they get out of bed when they shouldn’t,” Peterson said. “They don’t want to bother anybody.”

So, St. Luke’s is more frequently using bed alarms, in which a sensor from a patient’s gown to the bedframe lets nurses know if the patient is getting out of bed, Peterson said.

One of the challenges to bringing the numbers down is that hospitals are increasingly dealing with behavioral and mental health problems, Ehlinger said.

Essentia Health’s hospitals see those instances, Lyon said, and not just in units that are set aside for behavioral issues.

“One of our falls at St. Mary’s was a patient who was delirious, agitated and violent,” Lyon said. “It’s difficult to provide a safe environment for someone like that.”

Although falls and pressure ulcers are the most common preventable incidents, the state also tracks 26 other kinds of events. Two such incidents occurred in the Northland during the past year. A procedure was performed on the wrong body part at Essentia Health-Duluth and a foreign object was retained in a patient after a procedure at Lakewalk Surgery Center. Neither of those incidents resulted in death or serious injury, according to the state report.

The Essentia Health-Duluth incident occurred in surgery involving a patient’s fingers, Lyon said. One of the fingers that should have been operated on wasn’t, and another finger that shouldn’t have been operated on was. Although the fingers to be operated on were marked, as policies require, they weren’t marked as clearly as they should have been, Lyon said.

A call to Lakewalk Surgery Center about the incident there wasn’t returned.

The report noted improvements in some areas. The total number of pressure ulcers declined from 141 in 2011 to 130 last year; the number of retained foreign objects declined for the first time in five years, by 16 percent; and medication errors dropped by 75 percent to the lowest in the nine years the state has been tracking adverse events.

This is the ninth year that the state has reported adverse health events. Although a few other states now issue annual reports, Minnesota still is the only state that reports individual hospitals’ numbers, said Diane Rydrych, director of the Health Department’s health policy division.

The report doesn’t name the personnel involved in the mistakes.

A full copy of the adverse health events report and additional

information is available online at www.health.state.mn.us/patientsafety.

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