The number of adverse medical events reported last year increased both statewide — from 258 in 2013 to 308 in 2014 — and at Mayo Clinic Hospital - Rochester campus — from 29 to 44, according to the 2015 Minnesota Adverse Health Events reportreleased today.
The increase frustrates some observers, who hoped that Minnesota's 2003 requirement that hospitals report specific health mistakes each year would help identify and eliminate common errors. But since the present format of 28 categories was created in 2008, the overall number of mistakes has stayed roughly steady -- last year's total was down just four from the 312 reported in 2008, according to the reports from the Minnesota Department of Health.
Still, overall safety has improved under the law because problem areas are identified and solutions are found and shared, according to Dr. Timothy Morgenthaler, Mayo Clinic patient-safety officer.
"We have pooled our resources throughout Mayo Clinic so we can find best practices" to prevent falls, pressure ulcers, foreign objects left inside patients after surgeries and other problems, Morgenthaler said.
And some factors have prevented a drop in the mistake numbers -- each year hospitals added more overall patients, four new reporting categories were added this year, and the law itself has brought an increased awareness of reporting requirements and patient safety that may lead to more reports, medical experts point out.
The good news is that deaths were down. Overall, 13 deaths resulted from adverse health events in Minnesota in the reporting period from October 2013 to October 2014, the lowest number since 2011, the report says. Three of those deaths were reported at hospitals in southeastern Minnesota, including one fall, one suicide and a death because of failure to follow up on or communicate test results.
To address mistakes uncovered in the report, Mayo has taken steps such as giving every nursing unit access to pressure ulcer specialists, requiring surgery checklists and double-checks for fragments in patients after surgeries, and assessing patients for increased risk of falling, he said.
"I know we are getting better, because I see it in our procedures and in our patients," Morgenthaler said.
The numbers at Mayo Clinic Hospital in Rochester -- 44 adverse events in 2014, 29 in 2013 and 38 in 2012 -- reflect both the Saint Marys and Methodist Hospital campuses, which merged in 2014.
"But if there's a number (of medical errors) on this page, I'm upset about that and I want to make it better," he said. "Those numbers are people."
Statewide, the adverse events reporting system has inspired a number of efforts to analyze mistakes in specific areas, such as patient falls and surgical errors -- and come up with practices to prevent them, the report says.
"As in previous years, the majority of adverse events were tied to root causes in one of three areas: communication, policies/procedures and training/education," the report said.
This year, new patient safety efforts this year will focus on strategies to reduce lost or damaged biological specimens and to prevent errors in communicating test results, the report says.
There were four serious injuries and one death reported in Minnesota because of failure to follow up or communicate test results in the one-year report period, ending Oct. 6, 2014, the report says.
"Overall, these events were due to communication failures," the report said, both from the lab and between health providers.
In addition, there were 20 instances of the loss of an irreplaceable biological specimen, although no deaths or serious injuries resulted, the report says.
Morgenthaler praised the new focus on eliminating lost specimens and miscommunications in test results, because he said those errors are the "tip of the iceberg", as a large percentage of health care is done outside the hospital.
"I think it's a good idea to look at these, and to look at how these errors and mishaps are occurring," he said.
The majority of Mayo events were pressure ulcers, with 17, largely due to severe illness in the affected patients, Morgenthaler said. About two-thirds are not preventable with current methods, but one-third are, so there's "ample room for improvement," and Mayo is seeking new and better ways, he said.
There were six instances at Mayo Clinic Rochester of the retention of a foreign object in a patient after surgery or other procedure in 2014, the report says.
The hospital has become better at preventing retention of large items such as sponges, but a new challenge is the number of small items and device fragments being left in patients, Morgenthaler said. "There's just a lot more devices out there, and a lot more devices being used."
Mayo has had success reducing the number of wrong-site surgeries in recent years, and "we're working hard to eliminate them," he said.
"We're seeing improvements, but it's not good enough," he said. "We really want zero of these events to occur."
Statewide, the number of falls declined to 79 in 2014, with six fall-related deaths, from 81 the previous year, with 10 deaths, the report says. Also, wrong-site surgical procedures declined for the second consecutive year, from 27 in 2012 to 16 in 2014.
The four new categories this year are: failure to follow up on test results, loss of an irreplaceable biological specimen, neonatal death or serious injury associated with labor and delivery in a low-risk pregnancy and death or serious injury of a patient associated with the introduction of a metallic object into the MRI area.