Hospital errors up in Minnesota; Two newborn deaths reported in Northland

Two newborns died at Northland hospitals over a one-year period because of what a state agency calls "usually preventable" causes, according to an annual report released today.

Statewide, the Minnesota Department of Health reported 384 "adverse health events" from October 2017 to October 2018, the highest number in the last 10 years. The report, which was the first of its kind in the nation, counts on hospitals to self-report preventable incidents such as falls, pressure ulcers and medication errors.

Those events resulted in 118 serious injuries and 11 deaths during the past year, according to the report. Three of those were because of what the report describes as "death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy."

In the Northland, one of those deaths occurred at Essentia Health-Deer River and the other at Fairview Range Medical Center in Hibbing.

Dr. Rajesh Prabhu, patient safety officer for Essentia, said he wasn't directly involved in the review of the newborn's death in Deer River.

"I know a group of experts came together to look into that tragic event and see what could have been done better," he said. "My understanding is there was no, per se, one cause of that outcome."

An average of between 75 and 80 babies are born per year at the Deer River hospital, Essentia spokeswoman Shannon Dahnke said.

Fairview Range had 303 births in 2018, spokeswoman Jessica Schuster said.

Fairview didn't offer an interview, but responded in a statement: "We're deeply sorry when any adverse event occurs as our mission is to keep every patient who comes to our hospital safe. While we can't discuss specifics of these cases, we strive for zero preventable events and perform a root-cause analysis to see if there is anything we could have done differently and then share those learnings."

Dr. Rahul Koranne, chief medical officer for the Minnesota Hospital Association, noted that 64,000 births occurred in Minnesota during the reporting period. "These (newborn deaths) are extremely, extremely, extremely rare," he said.

Also in the Northland, St. Luke's hospital reported 20 "Stage 3, 4 or unstageable pressure ulcers," compared with two the year before. None involved serious injury.

Dr. Gary Peterson, the hospital's chief medical officer, said St. Luke's brought in a skin specialist from the Minnesota Hospital Association and formed a "skin committee" to determine what had gone wrong.

"What we encountered during the investigation is that most of these skin lesions were isolated to a couple of units where we had recently purchased some new equipment," Peterson said. "When we identified that, we took what we thought were appropriate measures rather promptly to address that."

Since October, when the reporting period closed, St. Luke's has seen a significant drop in pressure ulcers, he said.

Statewide, the number of pressure ulcers rose from 120 to 147, according to the report.

Carrie Mortrud, policy project specialist for the Minnesota Nurses Association, pointed to staffing issues as a possible explanation.

"You need people to turn patients who cannot turn themselves," Mortrud said. "If you've got such short staffing and/or staffing that's on the bare minimum, and there's crisis after crisis after crisis after crisis, nurses have to continually reprioritize. ... If you had more people around, then these other things could get done when they're supposed to."

She's hearing about staffing shortages from nurses, particularly at St. Luke's, Mortrud said.

"We know staffing has been a problem up there," she said.

Peterson said he doesn't work directly with nursing, but believes St. Luke's is adequately staffed.

Koranne also rejected inadequate staffing as an explanation.

"We have seen no correlation between these adverse health events and staffing at all," he said.

He also said that not all patients can be turned safely.

Two pressure ulcers were reported at Essentia Health-St. Mary's Medical Center, according to the report. Both resulted in serious injury.

The number of falls reported statewide dropped from 78 in 2017 to 71 in 2018, according to the report. In the Northland, two falls resulted in serious injury at Mercy Hospital in Moose Lake, and two resulted in serious injuries at Essentia Health-Duluth and one resulted in a serious injury at Essentia Health-St. Mary's Medical Center.

One of the more unusual findings was at Fairview Range, where, in the report's language, "a patient of any age, who does not have decision-making capacity, (was) discharged to the wrong person." The incident did not result in either death or serious injury.

Koranne said that in spite of the upward trend in numbers, the state's performance actually is improving. He pointed to data showing that "patient complexity" has increased by 20 percent in Minnesota since 2010. Moreover, he said, the rate of adverse health events hasn't changed since 2009. The rate both years was 0.006. That is computed by dividing the number of adverse health events by the number of "adjusted patient days," according to Emily Lowther, a Minnesota Hospital Association spokeswoman.

The specifics

The following are the adverse health events listed for Northland hospitals in the 15th annual report from the Minnesota Department of Health. The total number for the facility is indicated in parentheses. Severe injuries and deaths are noted when they occured.

Essentia Health-Duluth (2)

• Fall while being cared for in a facility - two events, both serious injuries

Essentia Health-St. Mary's Medical Center (5)

• Stage 3, 4 or unstageable pressure ulcers - two events, both serious injuries
• Fall while being cared for in a facility - one event, one serious injury
• Irretrievable loss of an irreplaceable biological specimen - one event
• Retention of a foreign object in a patient after surgery or other procedure - one event

Essentia Health-Virginia (3)

•  Irretrievable loss of an irreplaceable biological specimen - two events
• Wrong surgical/invasive procedure performed - one event

Essentia Health-Deer River (1)

• Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy - one event, death

Fairview Range Medical Center, Hibbing (3)

• The irretrievable loss of an irreplaceable biological specimen - one event
• Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy - one event, death
• A patient of any age, who does not have decision-making capacity, discharged to the wrong person - one event

Lakewalk Surgery Center (1)

• Retention of a foreign object in a patient after surgery or other procedure - one event

Mercy Hospital, Moose Lake (2)

• Fall while being cared for in a facility - two events, both serious injury

St. Luke's hospital (23)

• The irretrievable loss of an irreplaceable biological specimen - two events, one serious injury
• Stage 3, 4 or unstageable pressure ulcers - 20 events
• Fall while being care for in a facility - one event, one serious injury