Errors responsible for 15 deaths at Minnesota hospitals in 2013Fifteen patients died because of errors in Minnesota hospitals last year, according to an annual report from the Minnesota Department of Health.
By: John Lundy, Duluth News Tribune
Fifteen patients died because of errors in Minnesota hospitals last year, according to an annual report from the Minnesota Department of Health.
Two of the deaths occurred in the Northland: a death associated with “patient disappearance” at Grand Itasca Clinic and Hospital in Grand Rapids, and a death attributed to medication error at Community Memorial Hospital in Cloquet.
The “adverse health events” report, released Thursday, noted an overall decrease in the number of incidents reported from the year before, but little change in the number of more serious events. The number of deaths actually was up by one, but the total number of events — 258 — was down 18 percent from the previous year and below 300 for the first time since changes in 2007 broadened reporting, the health department said.
The total includes 84 “serious disability” incidents, down from 89 in 2012.
The year cited in the report doesn’t follow the calendar but ran from Oct. 7, 2012, through Oct. 6, 2013. The reporting system tracks 28 types of serious events, such as falls, wrong-site surgeries and serious medication errors.
The report showed a total of 10 adverse events at Northland hospitals, including one serious disability from a fall at Essentia Health-St. Mary’s Medical Center, one serious disability from a fall at Grand Itasca and two serious disabilities from falls at Fairview Range Regional Health Services.
Grand Itasca spokeswoman Cassi Chrzanowskisaid she couldn’t speak to the specifics of the incidents there.
“While each individual event is devastating, they also provide us, and our state’s entire health community, with an opportunity to learn,” she said in a prepared statement.
The incidents, which are self-reported by the hospitals, should be viewed in context of the number of patients seen at hospitals. Grand Itasca, for example, performed 14,860 surgeries and had 31,041 patient days in 2013, the report said.
The death attributed to the medication error was the only adverse health event reported by Community Memorial Hospital, which had 9,343 surgeries and invasive procedures and 13,479 patient days during the year.
Nancy DeRosier, the Cloquet hospital’s risk and compliance manager, said she couldn’t discuss the incident specifically.
But hospital staff had investigated the death to determine what went wrong and put systems in place to make sure it wouldn’t happen again, she said.
“We are very sorry that this happened, and we’re doing everything possible so that this does not happen again,” DeRosier said.
In Duluth, both health systems reported better numbers in 2013 than the year before.
Essentia Health-St. Mary’s Medical Center reported five incidents in 2012 and two last year, and two serious injuries in 2012 compared with one last year. Essentia Health-Duluth Clinic reported three serious injuries in 2012 and none last year.
St. Luke’s hospital, which had three serious injuries in 2012, had two reports of pressure ulcers last year, but no deaths or serious disabilities.
But even one adverse event is hard to take, said Dr. Gary Peterson, chief medical officer for St. Luke’s.
“We recognize that each of these events represents a patient and a family,” Peterson said. “We need to be constantly vigilant.”
St. Luke’s has increased programs designed to identify patients at a high risk for falls or pressure wounds, he said.
Likewise, Fairview Range is constantly in the process of upgrading safety, said Deb Boardman, CEO and president.
“One is too many, and we work hard to try to be sure that we don’t have many,” she said.
The report’s summary noted significant improvements, for the second straight year, in the number of pressure ulcers and the number of foreign objects — such as sponges and fragments of surgical instruments — retained in the patient’s body during procedures.
It also said the number of wrong body parts operated on was down 36 percent, the biggest drop in the report’s history.
Minnesota was the first state to pass a law requiring hospitals, and later ambulatory surgical centers, to report adverse health events, the report said. This was the report’s 10th year.
“Minnesota has been pretty committed” to the process, Fairview’s Boardman said. “I think we do it because it helps us all be better.”