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DCH avoids getting on medical mistake list

Not only was it a good year financially for Douglas County Hospital, 2007 also marked a successful surgical year. The hospital failed to make the fourth annual Minnesota Department of Health (MDH) adverse health events report - a report a hospita...

Not only was it a good year financially for Douglas County Hospital, 2007 also marked a successful surgical year.

The hospital failed to make the fourth annual Minnesota Department of Health (MDH) adverse health events report - a report a hospital doesn't want its name on.

"We work very hard not to get on that list," said Bill Flaig, hospital administrator. "I'm real proud of our staff, training and working day in and day out to prevent these kinds of occurrences."

DCH did, however, make the list last year when a sponge was left in a patient following a surgery. Thankfully, no serious disability or death occurred as a result of the mistake.

To ensure that it never happened again, the hospital established new procedures, including staff education on hospital retained foreign objects policy and procedure; clarified its surgical sponge count tracking document; instituted an ongoing sponge count audit process; and empowered all staff to call for a surgical sponge count at any time during a procedure.

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Hospital staff has also attended state safety initiatives to help ensure the "nevers" never happen.

Flaig said that with the thousands of patients seen each year at the hospital - about 8,000 inpatient and outpatient endoscopic procedures are performed annually - it's probably inevitable DCH will be on the list again.

"We're in a very serious business here, and we take that very seriously," he said. "Our number one concern is our patients."

Remaining transparent and viewing problems as opportunities to improve are key to success, Flaig said.

About the report

From October 7, 2006 to October 6, 2007, 38 Minnesota facilities reported a total of 125 adverse events, 13 deaths and 10 serious disabilities.

They're detailed in the state report, which was released last week.

Minnesota hospitals, ambulatory surgical centers and regional treatment centers have been required to report any of the "27 nevers" since the passage of the Adverse Health Events Reporting Law in 2003. It was the first of its kind in the nation.

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Although the report's numbers are down from last year, Minnesota Commissioner of Health Dr. Sanne Magnan anticipates they will increase next year.

"We're defining the definition of falls and pressure ulcers that will be reported," Magnan said. "We're raising the bar to make sure we are capturing and learning from a broader range of preventable events."

To see the full report, log on to the MDH Web site at www.health.state.mn.us and click on "patient safety." A consumer guide to the adverse health events is also available on the Web site.

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