Fairview errors aired

A state report lists three harmful errors at the University hospital during a 12-month period.

Operating on the wrong limb and leaving an object in a patient after surgery are two examples of medical errors that have happened at University Medical Center, Fairview.

The Adverse Health Events in Minnesota Public Report for 2006 was released Feb. 15, revealing that Fairview made three mistakes that caused harm to patients.

According to the 2005 report, the Minnesota Department of Health began compiling adverse event statistics in 2003 after Minnesota legislators passed a law requiring hospitals to keep records of these incidents.

The report considers six categories of adverse events: surgical, environmental, patient protection, care management, product or device and criminal.

Statewide, adverse event numbers remained similar to those in the 2005 report. However, deaths from these incidents decreased 60 percent from last year.

The number of events at Fairview has decreased from 13 in 2005 to three in 2006.

The most frequently documented events at Fairview in the 2005 report were bedsores and objects being left in patients after surgical procedures. The 2006 report documents zero incidents of either nature.

State hospitals do analyses of what went wrong and then explain why, said Diane Rydrych, author of the report.

Some of the reasons for hospital errors include communication breakdowns, not having the right documentation or chaos, she said.

Hospitals are required to report all incidents and the steps they are taking to prevent the error from happening again, Rydrych said.

According to the report, 106 incidences occurred among 2 million patients. There were more incidents of bedsores, but Rydrych expected that since the reports began there has been more focus on reporting bedsores.

Fairview has seen a sharp decrease in their errors since the 2005 report, said Alison Page, vice president of patient safety for Fairview Health Services.

The first incident at Fairview involved performing surgery on the wrong body part. The error left the patient disabled.

Fairview has a policy in which for every part thatís a pair, like ovaries or ears, left or right needs to be indicated on the consent forms. Errors can happen because of failure to follow the policy. For some body parts, there is a gray area of defining what is left or right, Page said.

Another incident at Fairview involving the malfunction of the device resulted in the death of a patient. The third incident involved an assault at the hospital.

Although Rydrych did not divulge specifics of the incidents at Fairview, examples of problems that can occur include the insertion of a tube into the wrong body part or an outside visitor coming into the hospital and assaulting a patient.

The process of preventing medical errors at Fairview is ongoing. It started before the report, but the report is helpful in determining policies, she said.

One possible partial explanation for the decrease in numbers is that the 2005 survey covered 15 months from July 1, 2003, to Oct. 6, 2004, while the 2006 survey covered 12 months from Oct. 7, 2004, to Oct. 6, 2005.

Fairview now is analyzing at-risk patients for bedsores and had a one-day seminar on how to prevent them. The center also is making sure patients are turned more often.

Fairview used consultants from the University to help identify process problems. They learned how to count items in the medical room and did observations to see how this policy plays out in real cases, said Carol Hamlin, director of departmental performance for Fairview.

Fairviewís biggest observation is that there are many interruptions while the people are counting medical instruments. Fairview is allowing nurses do a ìtimeout for patient safety,” Hamlin said, in which the nurses can take a break from other duties to finish counting items.