Hospitals want to learn from their mistakes

Talk about it

No one likes mistakes – especially in a medical setting when lives are on the line.

That’s why hospitals are trying to learn from any mistake they make.

According to a new report issued last week, there was one “adverse event” reported at the Douglas County Hospital in 2009. Wound packing material was left in a patient after a procedure.

The incident did not cause any serious disability or require additional surgery, according to the report issued by the Minnesota Department of Health (MDH).

Statewide, the number of adverse events in hospitals, ambulatory surgical centers and community behavioral health hospitals decreased from 312 to 301 in 2009.

The sixth annual report summarizes the number and types of events that occurred between October 7, 2008, and October 6, 2009, in the 199 facilities covered by the adverse health events reporting law. The 301 events were reported by 58 hospitals and four surgical centers.

It was the first adverse event at the Douglas County Hospital since 2006. That incident also involved a retained object left in a patient and did not result in any serious disability.

The hospital is not taking the incident lightly.

“Douglas County Hospital’s highest priority is the care and safety of our patients. Any adverse event is not acceptable,” said Bill Flaig, hospital administrator. “Our hospital, doctors and nurses will not rest until problems causing these events are corrected.”

Minnesota leads the nation on publicly reporting of adverse health events.

Douglas County Hospital, Flaig said, fully supports this program and sees it as an opportunity to improve and to share information between providers so that these types of events can be eliminated or greatly reduced.

Sponges and wound packing material are used to absorb excess body fluid during surgery or other procedures.

Sometimes it is difficult because a sponge soaked in blood can appear a lot like body tissue, making it difficult to see, Flaig explained.

In response, Douglas County Hospital participates in the State “Safe Account Campaign.” Two people, including a registered nurse, are assigned on each case for counting all items used before, during and after a procedure.

“Adverse events are never acceptable, and our goal is to eliminate these from occurring at Douglas County Hospital,” Flaig said.

Report highlights

The report shows that in 2009:

•Patient falls resulting in serious disability or death decreased by 20 percent, with no patient deaths from falls during the reporting year.

•Four patients died as a result of adverse health events, the lowest number in any reporting year.

•Events resulting in serious harm or death decreased slightly from the previous year, from 116 (37 percent) to 98 (33 percent).

•Serious pressure ulcers (bed sores) remained constant at 122.

•Wrong-patient, wrong-procedure, and wrong-site surgeries or invasive procedures increased slightly over the previous year, from 39 to 44.

•Retained foreign objects remained roughly constant, moving from 37 to 38.

Comments from health leaders

"The goal of our adverse health events system is not simply to report numbers, but to develop strategies to prevent adverse events," said Minnesota Commissioner of Health Dr. Sanne Magnan. "We believe the lessons learned and the steps taken in health care facilities across the state are helping to improve patient safety."

Magnan noted that the 20 percent decrease in falls likely reflects a recent initiative to prevent injuries and deaths from falls.

Over the past two years, more than 100 hospitals have participated in the Minnesota Hospital Association's (MHA) "Safe from Falls" campaign.

Since the campaign began in May 2007, participating hospitals have increased the average rate of implementing best practices for preventing falls from less than 60 percent to more than 90 percent.

For some best practices, including establishing an interdisciplinary falls prevention team and a system to alert staff about patient risk, the implementation rate is nearly 100 percent.

Lessons learned

In addition to making progress in preventing falls, Magnan said several key lessons were learned in 2009:

A number of reported pressure ulcers developed while patients were undergoing long surgical procedures, when the potential for skin breakdown was not sufficiently addressed.

In response to this finding, MHA worked with a group of wound care experts to develop recommendations for preventing pressure ulcers in the operating room.

Additionally, a quarter of reported pressure ulcers were related to the use of devices that pressed on or rubbed against the skin and contributed to skin breakdown.

A pressure ulcer advisory group will work in 2010 to develop recommendations for safer device use.

A number of reported cases of retained foreign objects involved broken or separated device components, or sponges or gauze that were intended to be removed after a period of time.

Both of these situations led to the release of safety alerts during 2009 and a statewide campaign by MHA to reduce retained foreign objects.

Future efforts to

address mistakes

In the coming year, MDH and its partners will continue to focus on identifying and sharing information about risks and successful strategies for preventing serious events, Magnan said.

Activities will include:

•Working with hospitals to implement MHA's "Safe Account," which Flaig mentioned earlier, to prevent retained objects in operating rooms and procedural areas.

•Improving scheduling processes to strengthen documentation of surgical sites and procedures and apply a more consistent approach for verifying patient information.

•Continuing to monitor trends and patterns in reported adverse events, and making data, case studies, and trend information more available to reporting facilities.

•Partnering with state and national organizations and facilities to promote consistent interpretation and investigation of adverse health events and application of best practices.

"Hospitals and surgical centers across Minnesota are very committed to preventing adverse health events," said Diane Rydrych, assistant director of the MDH Division of Health Policy. "While we may never be able to eliminate every adverse event, many people are working very hard to learn from past events and make future events as rare as possible."

About the ‘adverse events’ law

The legislation creating the adverse health events reporting system was supported by Minnesota hospitals and signed into law in 2003.

As initially passed, the law required all Minnesota hospitals, ambulatory surgical centers and regional treatment centers to report to MDH whenever any of 27 events occurred.

The National Quality Forum, a Washington, D.C.-based health care standards-setting organization, created this list of adverse events in 2002 at the request of the federal government.

This followed an Institute of Medicine report estimating that medical errors in hospitals cause 44,000 to 98,000 deaths every year in the United States.

In 2008, Minnesota hospitals reported more than 2.8 million patient days and more than 9 million outpatient registrations.

Ambulatory surgical centers reported nearly 210,000 registrations for same-day surgeries.

For more information

A full copy of the adverse health events report and additional information can be found on MDH's Adverse Health Events Web page, at www.health.state.mn.us/patientsafety. More information about hospitals can be found at www.mnhospitals.org.

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