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Report lists 'adverse events' at Northland hospitals

The wrong surgical or invasive procedure was performed. Another procedure was performed on the wrong body part. A biological specimen was mishandled and couldn't be replaced.

All of those mishaps occurred in Northland hospitals during a 12-month period in 2015-16, according to an annual report released today by the Minnesota Department of Health.

All told, 22 "adverse health events" were self-reported at Northeastern Minnesota hospitals from Oct. 7, 2015, through Oct. 6, 2016, according to the report, which is in its 13th year. The region's two largest hospitals — Essentia Health-St. Mary's Medical Center and St. Luke's hospital — accounted for eight of those apiece.

Most of the mishaps in Northland hospitals involved falls, each of which resulted in serious injury, according to the report.

The good news: No deaths were reported as a result of any of the adverse events in Northeastern Minnesota hospitals for the second year in a row.

Statewide, four deaths were reported, tied for the lowest number since the report began, and down from 16 in the 2014-15 report. But 106 of the 336 adverse events resulted in serious injury, the highest number reported to date.

The changes in those categories from year to year aren't statistically significant, said Rachel Jokela, who directs the health department's adverse health events program. But the change to fewer deaths and more serious injuries largely occurred in falls. She said that could be the result of efforts to limit the harm of falls when they occur.

"We really started focusing on the injury risk of falls, and not just the risk of falling," Jokela said.

One of the new efforts is to encourage hospitals to assume an unwitnessed fall involved a head injury and to react accordingly, she said.

Both St. Mary's in Duluth and Mercy Hospital in Moose Lake reported one instance of "the irretrievable loss of an irreplaceable biological specimen." An example of that, Jokela said, would be a colonoscopy in which a suspicious-looking polyp was removed and was sent for testing but never arrived at the laboratory.

Dr. Rajesh Prabhu, chief patient quality and safety officer for Essentia Health, said he couldn't discuss the specifics of the incident at St. Mary's, but he did say it had been thoroughly analyzed. A new software system would minimize the chances of a similar mishap occurring in the future, he said.

The hospital handles tens of thousands of specimens during the course of a year, Prabhu said.

Fairview Range Medical Center in Hibbing reported a surgery or other invasive procedure performed on the wrong body part, and St. Luke's reported a wrong surgical or invasive procedure being performed.

Dr. Gary Peterson, chief medical officer at St. Luke's, said he was "intimately involved" in the analysis of the error, which took place during an outpatient procedure.

"Our root cause analysis really uncovered a flaw in our system which caused it to happen," Peterson said. "It did result in some changes in our process for this particular procedure."

Jokela noted that such errors are rare statewide — 30 in the most recent reporting period out of more than 3.1 million surgeries and procedures. But that they occur at all is vexing, she said.

"There are pretty clear best practices that are out there ... and they're not consistently being done," she said.

Dr. Rahul Koranne, chief medical officer for the Minnesota Hospital Association, said the organization "has its own big, hairy, audacious actions that we're going to be taking, as we do every year," to respond to every category of adverse events.

For example, he said, the organization is advocating a "standardized timeout process" requiring all activities to stop before an operation to make sure everyone is on the same page.

Koranne said the number of mishaps is small in comparison with the number of patients the health systems serve. St. Mary's Medical Center, for example, performed close to 72,000 surgeries and invasive procedures during the reporting period, and St. Luke's close to 64,000.

Given the small numbers of adverse events, he doesn't get overly excited when the numbers go up or down slightly, Koranne said.

"This is not the stock market," he said. The annual release of the adverse events report "is a one-day show. ... What is much more important is what we do with the data 365 days a year."

But any number of adverse events is too many, Koranne said.

"Every single number is a patient and a family member," he said. "For every single one of these we are collectively and individually sorry that these events happened."

Adverse events, Northeastern Minnesota hospitals

  • Community Memorial Hospital, Cloquet — Fall while being cared for in the facility, 1 (serious injury)
  • Cook Hospital, Cook — Fall while being cared for in the facility, 1 (serious injury)
  • Essentia Health-St. Mary's Medical Center — Stage 3, 4 or unstageable pressure ulcers, 1; Fall while being cared for in the facility, 6 (all serious injuries); Irretrievable loss of an irreplaceable biological specimen, 1
  • Fairview Range Medical Center, Hibbing — Surgery/other invasive procedure performed on wrong body part, 1
  • Grand Itasca Clinic and Hospital — Fall while being cared for in a facility, 1 (serious injury)
  • Mercy Hospital, Moose Lake — Irretrievable loss of an irreplaceable biological specimen, 1; misuse or malfunction of device, 1 (serious injury)
  • St. Luke's hospital — Wrong surgical/invasive procedure performed, 1; Stage 3, 4 or unstageable pressure ulcers, 5; Fall while being cared for in the facility, 2 (both serious injuries)