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Mayo, others try to address error problem

By Jeff Hansel

jhansel@postbulletin.com

It's an unspoken truth: Any medical center can make a mistake.

But the problem is being addressed head-on by Mayo Clinic and other Minnesota medical centers.

In the past, errors were kept hush-hush at almost all hospitals.

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But publication of the Institute of Medicine's To Err Is human Report that said between 44,000 and 98,000 Americans die every year from medical mistakes caused a professional gasp among health workers in 1999. In Minnesota, that led hospitals to seek a law requiring preventable medical errors to be reported.

In 2005, Minnesota became the first state to report all 27 "never events" listed by the National Quality Forum as things that should never happen in the hospital setting.

The second annual report, published today, is the first to include ambulatory surgery centers -- and to cover a standard year's time frame from Oct. 7, 2004, to Oct. 6, 2005.

"Minnesota is a national leader when it comes to patient safety," said Mary Wakefield, the co-chair of the Quality Forum's Hospital Performance Measures Committee, according to the report.

"With the Minnesota reporting system and six other states having implemented the national standardized National Quality Forum Events, we can begin to learn and share information across the nation, as the Institute of Medicine recommended in the To Err Is Human report," said Wakefield.

The report says most "adverse health events" or medical errors happen because of problems with systems, rather than an individual's negligence.

The Minnesota Hospital Association said Monday that three statewide alerts were issued after problems were noticed during the year:

When a heart monitor was delivered to facilities, it was sometimes turned on, sometimes turned off and sometimes left in test mode. Hospitals were advised to develop a method to make sure it's on.

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A device that wasn't compatible with an MRI machine malfunctioned at one facility in a "near miss," meaning no one was harmed. But other facilities were alerted to the potential problem to prevent harm elsewhere.

Operating room staff "pause for the cause" to make sure the patient is the right one, and that they're going to operate on the right spot and perform the right procedure. But data showed the same thing needed to be done when procedures are done outside the operating room.

Hospital Association president Bruce Rueben urged patients to ask questions about safety.

"Those are the kind of questions that keep people alert to their own safety, and also keep the caregivers alert about it also," Rueben said. If a doctor balks at such questions, Rueben said, find another doctor.

Medical facilities write a "plan of correction" for each never event that occurs, seeking to find ways to prevent it from ever happening again. The state reviews those plans to make sure they're effective and shares the plans with hospitals statewide.

The report recommends things patients can do to protect their safety.

To prevent surgical errors, pick a facility where many patients have had the procedure you need. Make sure you, your doctor and your surgeon all agree and are clear on exactly what will be done. If possible, verify that your surgeon has marked the correct surgical site with indelible ink.

To prevent pressure ulcers, inspect your own skin and make sure your caregivers do so daily. Limit pressure by moving often. Ask questions to understand your care.

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To prevent medication errors, keep track of medicines you're taking and make sure all your doctors know everything you are taking. Make sure you can read the handwriting on your prescription. When prescribed a new medicine, ask if it is safe to take with other medicines or supplements. When you pick the medicine up from the pharmacy, ask, "Is this the medicine that my doctor prescribed?"

By definition, Rueben said, never events are rare. But Minnesota health providers want to keep them from happening because even one such event can be devastating to the patient, family and caregivers. The fact that all Minnesota acute-care hospitals report their never events, he said, "is a really powerful sign."

"It's regrettable even one of these things has happened, and the whole point here is to decrease or eliminate these things," Rueben said.

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