Fewer hospital errors reported in latest Minnesota report
(AP) - Minnesota hospitals made fewer serious mistakes and fewer patients died as a result of the errors, according to the state's latest accounting of hospitals' worst failings.
Hospitals reported 125 serious problems from October 2006 to October 2007, including 13 linked to patient deaths and 10 that resulted in serious disability for patients.
That compares to 154 mistakes the year before, including 24 deadly ones. Errors ranged from advanced bed sores to operations on the wrong body part.
The Minnesota Health Department released its annual "Adverse Events" report on Thursday, providing a glimpse into 27 preventable hospital problems that officials hope to stamp out through the state's first-in-the-nation reporting system.
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Health Commissioner Sanne Magnan and Bruce Rueben, head of the Minnesota Hospital Association, said the goal of publicizing the mistakes is to make hospitals safer for patients.
"I applaud people who are bringing forth what's actually happening in their institution and reporting the numbers," Magnan said in an interview Wednesday.
The most errors - 12 - were reported by Saint Marys Hospital, the Mayo Clinic's flagship in Rochester. Saint Marys also topped the list with three patient deaths and three errors that disabled patients.
Two deaths were attributed to malfunctioning medical devices. Another patient died after developing an embolism during open-heart surgery, said Dr. Michael Rock, chief medical officer for Mayo's Rochester hospitals.
The goal of publicizing the mistakes is to make hospitals safer for patients.
The number was high because Saint Marys is one of Minnesota's biggest hospitals, Rock said. Its error rate is comparable to the statewide rate, about 4 to 5 mistakes per 100,000 patient days, he said.
"We take each one of them seriously," Rock said of the errors. "We, within hours if not several days, review the particular event with all the stakeholders and bring experts to the table as necessary."
Since October, mistakes and corrective actions have been shared among Mayo's entire staff in an effort to make employees aware of the problems and prompt them to share information that could help avoid future errors, Rock said.
Most mistakes boil down to communication gaps - an area they're working on, he said. One surgeon has started a process where every member of the surgical team speaks up before procedures.
Solutions like those are available to other hospitals through an online state registry, making Minnesota the only state where hospitals share their analyses of errors and plans to fix them, said Bruce Rueben, president of the Minnesota Hospital Association.
"This is still pretty new, and you have a very robust, aggressive reporting approach in Rochester. I think they're to be commended," Rueben said.
Hospitals can't charge patients or insurers for care made necessary by a medical mistake, a policy that went statewide in September.
Blue Cross and Blue Shield of Minnesota has had the policy for four years, but the point isn't to save money, according to MaryAnn Stump, the insurer's chief innovation officer.
"It really has a lot to do with walking the talk with what it is you're trying to accomplish," she said.
Six other states - California, Colorado, Illinois, Indiana, Massachusetts and New York - have enacted hospital error reporting laws, but not all have implemented them, said Jennifer Sweeney, health care quality project at the National Partnership for Women and Families in Washington.
Sweeney wants more consumers to know about the report and use it to guide their decisions. She urged Minnesota to start a campaign to publicize the data to patients.
"I don't think that most consumers are aware that this information is available," Sweeney said.
The Health Department offers an online consumer guide to go along with the report, available on its Web site, said Diane Rydrych, the report's author. Several thousand people downloaded the report last year, and consumer organizations and patient advocacy groups also were informed of the report.
Next year, Magnan expects hospitals to report more errors as they start counting another mistake - inseminating a patient with the wrong donor sperm or egg - and expand the definition of falls and bed sores to include new cases. She said it's part of the push toward transparency and accountability.
(Copyright 2008 by The Associated Press. All Rights Reserved.)
