Home » Malpractice » Hospital Malpractice »

Deaths from hospital errors, mishaps still rise

Mar 22, 2010 | Maura Lerner | The Star Tribune

 Minnesota hospital mistakes and incidents climbed for the second year in a row, according to a Health Department report. The death toll rose to 24 from 12.

In spite of a major push to improve patient safety, 24 people died from medical mistakes or accidents at Minnesota hospitals last year, twice as many as the year before, according to a report by the Minnesota Department of Health.

Half the deaths were blamed on falls. Another patient died after an unidentified "foreign object" was left behind during surgery, and two other deaths were attributed to medication errors.

Overall, there was a 50 percent increase in the number of "adverse events" reported by hospitals and surgical centers between October 2005 and October 2006, according to the third annual state report, which will be released today.

The report, which tracks the most common and serious threats to patient safety, found 154 incidents statewide, up from 106 the year before. Most caused no permanent harm, officials said, but seven people were left severely disabled.

Hospital officials say they're finding more mistakes now in part because they're looking harder for them.

Health Commissioner Dianne Mandernach said it's difficult to explain the increase in deaths. "I'm struggling to say why it would be doubled," she said.

At the same time, Mandernach said the report is doing what it was meant to do -- shining a light on a complex problem. "It's not about coming up with a number," she said. "The reality is, this is all about trying to fix the system to make sure that it doesn't happen again."

For the past three years, hospitals in Minnesota have been required to report 27 types of incidents, known as "never events" -- because they're never supposed to happen.

So far, Minnesota is the only state to publicly disclose the errors, with a summary of the incidents at each hospital, although no patient details are released.

Topping the list were serious bedsores (48 cases), followed by objects left behind in surgery, mostly sponges and tiny needles (42 cases).

In three cases, the wrong patient received a medical procedure, the report found.

In one case, a patient at Methodist Hospital in Rochester had an unnecessary biopsy after receiving the wrong lab results, said Dr. Michael Rock, chief medical officer for the Mayo Clinic's hospitals. "It was a mixup," he said. Fortunately, he said, the patient was unharmed, and the problem was quickly discovered.

In Waconia, another patient got the wrong biopsy results, resulting in a brief scare, said Dr. Rob Welch, chief operating officer of Ridgeview Medical Center.

"Fortunately, the patient did not have surgery," he said.

Instead, the patient had another diagnostic procedure, which turned up clean. "The greatest harm was thinking that there was a diagnosis that wasn't in fact true," he said. As a result, the hospital revamped its handling of lab results, to help ensure that they go to the right patient.

Some of the rarest events were the most deadly: three patients committed suicide while hospitalized and two disappeared from their hospital beds and died, according to the report. Hospital officials would not talk about the cases, except to say that some people leave against medical advice.

"Obviously, when we look at those numbers we are very concerned and disappointed," said Alison Page, chief safety officer for Fairview Health Services, which had eight patient deaths at four hospitals.

Patients want apologies

"Even when they're not harmed, when there's a mistake made, what people want is an apology," she said. "And most people really want to know how are you going to make sure this doesn't happen to the next person."

In the last few years, hospitals throughout Minnesota have been scrambling to put new rules in place to prevent mistakes.

At the University of Minnesota Medical Center, for example, surgeons now sign their initials directly on the body part where they plan to operate. And before surgery, nurses list every clean sponge and needle on a whiteboard on the wall, to help ensure that they leave nothing in the patient.

Many of these things have been done for years. But now the hospitals are trying to standardize them, so everyone does them the same way every time, according to patient safety experts.

Carolyn Pare, who has criticized hospitals for being slow to change, said they still have a ways to go. Pare, who heads a business coalition called the Buyers Health Care Action Group, said it's unnerving that the same mistakes keep happening, such as leaving foreign objects in patients.

"I don't care if you tell me it was just a little needle or a big honking sponge, obviously the process isn't ensuring 100 percent," she said. "The consumer still needs to recognize that these are things that are never supposed to happen."