MINNEAPOLIS — While adverse health events reached a new high, accidental hospital deaths saw a precipitous drop in 2016, according to the 13th annual report compiled by Minnesota Department of Health.
Minnesota facilities reported 336 adverse health events between Oct. 7, 2015, and Oct. 6, 2016, according to the 101-page report. That number had not been higher than 316 since 2008.
However, the number of reported deaths dropped to four, which matches the number from 2009; the average number of accidental hospital deaths between those years was 12. An additional 106 serious injuries also occurred, including 10 at Mayo Clinic Hospital in Rochester.
Despite some progress at the state and local level, Dr. Timothy Morgenthaler, Mayo's patient safety officer, said he was "disappointed" with the latest report.
"We want that number to be zero," Morgenthaler said. "We have as our goal to be the safest place on the planet to be a patient."
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Morgenthaler cautioned there's a "double aspect" of the MDH reports, which are now focusing on details that previously may have been overlooked. That's prompted health care facilities across the state to improve standards, even if that isn't necessarily being reflected in MDH's numbers.
"You'd like to believe that we're getting safer and safer," Morganthaler said. "I know within Mayo Clinic and other organizations across the state, there's an awful lot of work being done to improve patient safety. We all take those numbers very seriously … and I'm hopeful that we're starting to see the fruits of those efforts."
Among the positive developments highlighted by the study:
• Fall-related deaths were the lowest since 2011.
• Neonatal death or serious injury associated with labor and delivery in a low-risk pregnancy declined to two events.
• The suicide/attempted suicide/self-harm event category saw zero deaths for the first time since 2011.
"More than 15 years after the publication of the Institute of Medicine's landmark report on patient safety, 'To Err is Human,' it is more clear than ever that the health care system's journey toward zero instances of preventable harm has led to both significant progress and learning about why serious events happen and how to prevent them — and a recognition that there will always be more work to do," reads the report's executive summary.
Mayo's mixed numbers
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Mayo Clinic's numbers ticked up in 2016 but not in an egregious way. Mayo Hospital in Rochester reported 38 adverse health events that caused zero deaths and 10 serious injuries. That number is up from 31 in 2015 but down from 44 in 2014.
Of the 10 serious injuries, eight were caused by falls. Morgenthaler said falls have been addressed by Mayo's enterprise fall reduction group by turning it into a system focus.
Another serious injury was caused by "failure to follow up or communicate laboratory, pathology, or radiology test results," and the final one was caused by the misuse or malfunction of a device.
Additionally, the Rochester facility performed three surgeries/invasive procedures on the wrong body part and five times performed the wrong surgical/invasive procedure. Those eight events represent a minuscule percentage of mistakes during Mayo's 332,021 surgeries or invasive procedures that were performed during the study period.
The Rochester facility reported 538,077 patient days during the study period, which is by far the most reported by a single facility reviewed in the study. Only the University of Minnesota Medical Center reported even half that many patient days.
The most common issue reported across the state was pressure ulcers, or bed sores, with 129 events. Mayo reported 14 of those incidents at its Rochester facility.
Morgenthaler said most of those were from ICU patients on breathing or feeding tubes from early in the study period, which prompted Mayo to seek advice from skin care experts to learn new techniques.
"We've actually had remarkable improvement," Morgenthaler said.
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Mayo Clinic employs all 115 best practices recommended by the Minnesota Hospital Association and received several Save Our Skin awards in 2013. Every Mayo care unit is staffed by nurses who are skilled at recognizing and responding to symptoms. When pressure ulcers are reported, Mayo teams thoroughly investigate to uncover causes and address them through systems improvements.
MCHS lags behind
Mayo Clinic Health System reported 13 adverse health events in 2016, up from eight in 2013. Those incidents included five that caused serious injuries, according to the report.
The bulk of those issues were reported at Mayo's Mankato facility, which had nine adverse health events and two serious injuries. One injury was suffered during a fall, while the other was due to "retention of a foreign object in a patient after surgery or other procedure."
Mankato also performed four surgeries or invasive procedures on the wrong body part. That's equal to once every 9,295 times, making it roughly 11 times more likely to occur than the state average of about once per 103,000 procedures.
"We recognize that's not a good trend to see," Morgenthaler said of Mankato. "Some of those (issues) happened early on in the year, and there has been scrupulous attention to universal protocol and (post-procedure) debriefs. We're hopeful that we'll be looking a lot safer next year."
Mayo's Austin facility reported two serious injuries in 2016. One was the result of a fall, and the other was "due to medication error."
Cannon Falls suffered one serious injury due to a fall, and Albert Lea also reported one serious injury due to "failure to follow up or communicate laboratory, pathology, or radiology test results."
