Fairview sees fewer mistakes

Although problems persist, practices to prevent avoidable mistakes have proven to be effective.

Tara Bannow

The University of Minnesota Medical Center, Fairview reported a total of 41 mistakes in 2009, down from 52 in 2008, a trend one hospital official attributes to stringent implementation of âÄúbest practices.âÄù In order to avoid performing the wrong surgeries or performing them on the wrong body part âÄî a mistake that happened six times last year âÄî the hospital has made it a point to take âÄútime outsâÄù before operations, Susan Noaker, FairviewâÄôs senior director of quality and patient safety, said. âÄúThereâÄôs sort of a briefing or a pause where we make sure everybodyâÄôs on the same page,âÄù she said. Cases in this category dropped one from last year, as did retention of a foreign object in a patient after surgery, which happened four times last year. The hospital collects this information as part of the Minnesota Department of HealthâÄôs annual Adverse Health Care Events Reporting System. In total, the number of mistakes was down 3.5 percent âÄî or 301 from 312 âÄî among the 199 facilities included in the report. Statistically speaking, the statewide improvement is not significant, although itâÄôs always good to see, said Diane Rydrych, assistant director in the division of health policy for the MDH. Fairview uses an electronic reporting system called I-Care, where employees report all mistakes. âÄúWe really emphasize reporting, investigation to learn and then fixing that problem to prevent it from occurring in the future,âÄù Noaker said. As a major teaching institution, Fairview houses 340 University medical students serving three to seven-year residencies. Depending on their level, resident physicians perform everything from physical examinations to complex brain surgery, Louis Ling, associate dean for graduate medical education, said. The hospital also has students participating in other programs, such as clinical rotations. Hennepin County Medical Center houses 100 University residents in addition to the 250 students in HCMCâÄôs own residency program, Ling said. Errors at HCMC increased from 11 in 2008 to 24 in 2009, most of which were pressure ulcers that did not result in serious disability. While each student is taught the hospitalâÄôs error prevention protocols, the students do create additional risks for mistakes, Ling said. âÄúResidents do make it more complex,âÄù he said. âÄúThereâÄôs more people involved in patient care and more chances for miscommunication.âÄù Nonetheless, the residents provide patients with more opinions and care, he said. Overall, the ratio of mistakes to the number of patients and surgeries performed at Fairview has stayed comparable to other Minnesota hospitals over the years. Although Fairview usually sees more mistakes than other facilities, itâÄôs common to see a correlation between size and number of events, Rydrych said. Stage three or four pressure ulcers âÄî tissue damage that occurs when a patient stays in the same position too long âÄî continue to be an issue for Fairview. Although down 15 from last year, the hospital still saw 20 pressure ulcers last year. The hospital has virtually eliminated what it considers to be âÄúpreventableâÄù pressure ulcers, Noaker said. Those that happen are considered unavoidable. Some patients have co-morbidities and either canâÄôt or refuse to be moved, she said. âÄúItâÄôs now becoming almost a research question,âÄù she said. To alleviate the number of wrong site surgeries performed, Fairview is piloting a technique in their operating rooms of confirming with the patient where their surgery is supposed to happen, Noaker said. Overall, this is a practice the MDH is moving away from, as patients often get confused, especially when it comes to moles and lumps, Rydrych said. A law put into effect in 2003 required the MDH to collect information from every hospital in the state. Hospitals were required to report any of 28 serious events, along with the corrections implemented afterward and recommendations for improvement. Between 2007 and 2008, the category for reporting the number of surgeries and invasive procedures expanded to include minor surgical events such as performing a biopsy or inserting a chest tube, causing a major spike in numbers. Minnesota was the first state to implement such a reporting system. Since then, 26 other states have begun to do the same. Although the reporting system has had an impact, when it comes to solving complex internal issues in hospitals, thereâÄôs no easy fix, Rydrych said. âÄúItâÄôs not as easy as âÄòYou need to write this down hereâÄô or âÄòYou need to take this simple step,âÄô âÄù she said. âÄúIt kind of gets at the whole culture of an organization âÄî and that can take a long time to fix.âÄù