Medical errors increase in Minnesota hospitals, report says

Mistakes made inside Minnesota hospitals are on the rise, according to a Minnesota Department of Health report. 

For the last 14 years, MDH has been tracking the number of times hospitals and surgical centers report what they call adverse events. Often times, these are simple mistakes made by health care workers, but that number has been increasing over the last four years. 

The reporting system tracks 29 serious events, including wrong-site surgeries, severe pressure ulcers, falls and serious medication errors.

A total of 341 mistakes were reported between October 2016 and October 2017. There were 103 serious injuries and 12 deaths reported, according to the 14th Annual Public Report from the Adverse Health Events reporting system.

“The recent rise in adverse events is concerning,” said Health Commissioner Jan Malcom. “Minnesota can and must do better to protect vulnerable patients. We will continue to work with our partners to improve patient safety and the quality of care in our state.” 

In 2017, five of the 12 deaths were associated with falls. Two deaths were associated with air embolism—a blockage of blood supply caused by air bubbles in a blood vessel or the heart. Other deaths were associated with the death of a neonate, a maternal death, suicide/attempted suicide and medication errors. 

There were 55 cases involving wrong surgeries, wrong-site surgeries, and left or retained objects, the annual report stated. However, these mistakes are rare since there were 3.1 million surgeries and invasive procedures during the year. 

“Behind each of these events is a patient and a family,” said Dr. Rahul Koranne, chief medical officer of the Minnesota Hospital Association. “Minnesota’s nation-leading adverse health events reporting system provides a strong framework for learning and continuous quality improvement—and our hospitals, health systems and care teams use what they learn to continually improve patient safety.” 

While the number of errors increased, overall the report also showed improvements with a drop in the number of bedsores. And for the first time in six years, there were not any reports of physical assault on staff or patients. 

Additional trainings and safety alerts related to medication errors involving epinephrine and pressure ulcers were implemented by the Minnesota Department of Health and the Minnesota Hospital Association. The MHA also hosted a medication safety conference about controlled substance diversion, culture of safety and medication reconciliation.