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Adverse events up, report says

The U’s medical center had more adverse health events in 2015 data than the past year’s.

Doctors at the University of Minnesota Medical Center left more foreign objects in their patients during surgery last year than they did the year before, according to state data.

Adverse Health Events for Minneapolis Hospitals, 2010-2015

Adverse health events like this at UMMC jumped to 31 last year compared to 26 the year before, according to a 2015 Minnesota Department of Health report. This increase follows four years of steady drops in number of adverse health events, which include patients falling down, sexual assaults and items left in patients after surgery.

The state health department annually logs this data on hospitals using an October-to-October cycle. For example, last year’s data was measured from October 2013 through October 2014.

All state hospitals are required by law to report adverse health events to the department.

And while hospitals are required to submit a record of the events, the health department doesn’t track whether hospitals document them. This means the frequency of the events could be skewed if hospitals don’t report them, said Dr. Timothy Morgenthaler, a patient safety officer and professor of pulmonary critical care medicine at the Mayo Clinic.

The incidents tracked fall under 29 categories that are broken into seven classes including surgical/procedural events and care management events.

“Nobody comes into the hospital to harm someone,” said UMMC spokeswoman Jennifer Amundson. “When something like this occurs, people want to know why it happened.”

Amundson said though the total number of events at UMMC increased from 2013 to 2014, the statistics should be considered in relation to the number of patients the hospital saw last year — which was about 343,000 according to the 2015 report.

Rochester’s Mayo Clinic saw a similar increase from 29 to 44 reported events with about 438,000 patient visits last year. Most of Mayo Clinic’s incidents were retained foreign objects after a procedure and patients falling while under hospital care.

Dr. Jeffrey Chipman, UMMC general surgeon and associate professor in the Medical School, said the hospital educates physicians about patient safety on a weekly basis.

He said doctors have to complete a series of precautionary measures to ensure they don’t make mistakes during daily tasks like surgical procedures and giving medication.

But even after using such deliberate preventative methods, Morgenthaler said doctors should always work to improve carefulness with patients.

Doctors evaluate all adverse events, and about two-thirds of the time they conclude that every precautionary measure was taken. But the other third of the time, doctors realize they could have done more.

“We tend to be quite hard on ourselves because we’re trying to constantly figure out new ways to do better,” Morgenthaler said. “Each one of these numbers is a person.”

Sometimes, Chipman said, a physician will take all necessary precautions, but a patient’s pre-existing condition will inevitably lead to an adverse event, like if an obese person gets a bed sore.

“A patient’s condition brings a lot of things to the table,” he said.

Fluctuation in stats

“To Err is Human,” a paper released in 1999 by the Institute of Medicine, recommended that governments begin accountability programs to promote transparency with the public on things going wrong — a suggestion Minnesota’s health department took to heart.

“It was really a big game-changer for patient safety in saying how many thousands and thousands of people are dying every year from these medical errors and that we need to do something about it,” said Rachel Jokela, adverse health events program director for the state’s health department.

Since the department released its first report in 2005, UMMC has seen a steady increase of reports of foreign objects left in patients and a decrease in patients falling in the hospital.

In 2013, the Medical Center reported seven patient falls. This year, it reported four.

Retained Foreign Objects and Patient Falls at UMMC, 2010-2015

Balancing safety, independence

Chipman said at the University’s Medical Center, patients who are at high risk for falling are marked with a wristband. Those patients have a motion alarm placed next to their beds that sounds whenever they attempt to get up without a doctor or nurse’s supervision to do things like use the restroom.

Physicians have to find a healthy balance between protecting patients and allowing them to feel independent.

“If we stapled everybody to the bed, then we would have no falls,” Morgenthaler said. “But that also is ignoring entirely their dignity and uniqueness as an individual.”

Chipman said he runs through a course of precautionary steps with his surgical team before and after surgery. The team takes precautions like checking to be sure they’re operating on the correct limb and counting utensils before and after surgery, he said.

But mistakes are made, he said, because not every case is identical. UMMC reported four instances where an item was left in a patient after surgery last year. This year’s report shows eight.

“When a pilot goes and flies a 737, every 737 is the same,” Chipman said. “But you can remove a gallbladder on a patient, and it’s different every time.”

Surgeons have abandoned large surgical instruments and started using microscopic tools in recent years, causing more cases in which fragments of tools are left in patients, Morgenthaler said.

“This is going to require a whole new kind of scrutiny,” he said.

The fluctuation in numbers of foreign objects left behind and patients falling isn’t entirely due to the care and attention paid by hospital staff, Chipman said.

Hospital workers across the board agree that despite efforts focusing on patient safety, there’s always opportunity to grow.

“Our goal is to be the safest place on the planet to be a patient,” Morgenthaler said.

Although Jokela said doctors across Minnesota have improved over the past 10 years, they always strive for fewer occurrences.

“I definitely think that we’re safer than we were, but I think there’s still room to improve,” Jokela said. “There always will be.”

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