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2012 report on patient harm — and protection

Tricia Alvarado, a nurse manager at Regions Hospital in St. Paul, shows on Wednesday how gel pads are used in surgery to help prevent pressure ulcers on a patient.

Hospitals in southeastern Minnesota reported six instances of serious patient harm in the state's 2012 Adverse Health Events assessment .

Seven were reported the previous year by Mayo Clinic's Saint Marys and Rochester Methodist hospitals alone.

The total number of patient falls, pressure ulcers, wrong-site surgeries and other preventable patient problems at Minnesota hospitals and ambulatory surgery centers increased slightly, from 305 in the 2011 report to 316 in this year's, the Minnesota Department of Health said.

But the increase "serves to mask significant improvements in two areas where Minnesota has implemented strong, statewide efforts over the last few years, falls and wrong-site surgeries," the health department noted.

The Minnesota Legislature passed the first and most comprehensive mandatory adverse events reporting system in the country at the urging of the state's hospitals.


Mayo Clinic results mirror statewide ones in that "overall level of harm seems to have decreased, and the number of pressure ulcers has kind of remained elevated or even climbed somewhat," said the clinic's patient safety officer,  Dr. Tim Morgenthaler .

Pressure ulcers occur when pressure or friction causes tissue underlying skin to become inflamed. If left untreated, a serious, even life-threatening, open wound can form. Mayo takes such wounds very seriously, Morgenthaler said, but they're difficult to prevent altogether.

"We're going to figure it out," he said. "We're going to find a way. But I don't think that the existing science allows us to prevent every single one."

In the meantime, Mayo has teams that will review every pressure ulcer event, expanding to include emergency department stays before transfer to a room and the potential effect of gurney use on patients.

Medical devices increasingly trigger pressure ulcers — including a third of the ones in Minnesota reported as adverse events this year, according to Diane Rydrych, Department of Health Policy Division director.  Examples include head braces, oxygen tubing at the ears and endotracheal tubes. Complicating the pressure-ulcer issue is a change in patient status.

Patients arrive with more medical problems or "co-morbidities," said Commissioner of Health Dr. Ed Ehlinger .

"They weigh more. They're obese. They have diabetes. They need more intensive, technical kinds of interventions," Ehlinger said. "And all of these things put people at risk of pressure ulcers. So we're looking at a population that's getting older and getting sicker and have more co-morbidities that increase their risk."

Ehlinger said it's important to put the adverse events in context with Minnesota's 2.6 million "patient days'" worth of hospital time, 10 million outpatient registrations and 200,000 same-day surgeries during the reporting period.


Health organization leaders must make patient safety a priority, the health department says. But things like falls prevention are a team task.

"It needs to be a community-wide approach of hospitals, patient-safety organizations and patients themselves," Ehlinger said.

In Rochester:

• Olmsted Medical Center reported no adverse events, serious or otherwise.

• Saint Marys Hospital reported a single serious event in the 2012 report — a fatality that resulted from a patient fall, as well as three retention of a foreign object after surgery with no serious disability; one procedure on the wrong body part with no serious disability; two wrong procedures with no serious disability; and 38 stage 3 or 4, or unstageable, pressure ulcers with no serious disability. The previous year, Saint Marys reported one death from a fall and four falls causing serious disability, along with one patient who attempted suicide resulting in serious disability.

• Rochester Methodist hospital reported three events in the 2012 report that caused serious disability, one from a device malfunction and two from patient falls. It also reported two wrong-site surgeries/procedures not resulting in serious disability; four wrong procedures with no serious disability; and three "care management" events with no serious disability. The prior year, Rochester Methodist reported one serious disability resulting from a medication error and one fall resulting in serious disability.

• Mayo Clinic Health System in Austin reported a single instance of a serious disability due to a medication error.

"As happy, I think, as we are that we're not listed in the report, that doesn't mean that we can rest on our laurels," said Olmsted Medical Center spokesman Jeremy Salucka. OMC will continue to encourage hard-stops before each surgery to verify patient identity and staff roles and to encourage staff members to halt a procedure at any time to raise a concern. 


Systems that prevent adverse events are key to reducing them.

"This is a system issue. There has to be a system put in place so there are multiple accountabilities," Ehlinger said. "If you don't have those systems put in place, you will never be the best you can be."

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