Serious medical errors rising in Minnesota

Minnesota health officials say the number of cases of seriously flawed medical care in hospitals and surgery centers has been rising over the last four years. These errors are referred to "adverse events" and state officials say they should occur rarely at most.

Care providers reported 341 "adverse events" from October 2016 through September 2017. They included 12 deaths and more than 100 serious injuries. Two-thirds did not lead to death or serious injury. Still, Health Commissioner Jan Malcolm declared the findings a problem.

"This steady rise in reportable adverse events is concerning and we should not consider this acceptable," said Malcolm of the new data.

Statewide, the most commonly reported adverse event was advanced stage pressure ulcers, or bed sores, which look like a crater in a patient's flesh.

But out of 120 total events, there were no reported deaths and only two serious injuries related to bed sores.

The second most common adverse event was also the deadliest. Falls in care facilities accounted for five of the 12 reported deaths and 77 serious injuries.

At Mercy Hospital's Unity Campus in Fridley, there were five adverse events, all producing serious injury except for the criminal case of care delivered by someone impersonating a health care provider.

Malcom called attention to the growing number of mistakes in surgical or invasive procedures. She called for more careful surgery preparations.

"We saw a troubling increase in surgical or invasive procedure events. There were 55 of these cases during this reporting period, which is significantly higher than the average over the 14 years that we've been doing this report," Malcolm said.

Although 55 is a concerning number, it represents 0.002 percent of the more than 3 million surgeries or invasive procedures conducted during the yearlong reporting period. Minnesota law requires care givers to report 29 categories of "adverse health events" in the hope the information will lead to safer practices.

The Minnesota Hospital Association says hospitals and health systems have learned a great deal from the annual report over its 14 years.

"We are concerned for every single one of these events because when we look at these numbers what we see are patients, their families and our communities," said Dr. Rahul Koranne, the association's chief medical officer.

Koranne said the real-time reporting of "adverse events" had led to rapid changes to best practices. Just in the last year, the data prompted an alert to halt medication errors with the drug epinephrine.

"I shudder to think what the scenario would be like if we didn't have this real-time learning system, so I think the system is absolutely working," Koranne said.

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