Medical Errors Led to 20 Deaths in Minnesota Hospitals Over 15-Month Period, Study Finds
Twenty patients in Minnesota hospitals over a 15-month period died as a result of medical errors, such as falls, medication errors and problems with medical equipment, according to a study released on Wednesday by the Minnesota Department of Health, the AP/Las Vegas Sun reports (Lohn, AP/Las Vegas Sun, 1/20). The study was mandated by a 2003 Minnesota law that requires hospitals to report to the state 27 categories of medical errors developed by the National Quality Forum. The 27 categories include surgery performed on incorrect body parts or patients, foreign objects left in patients after surgery, electric shock, burns or falls, medication errors, abduction and assaults in hospitals. The study involved all 145 hospitals in the state and included medical error data collected between July 1, 2003, and Oct. 6, 2004 (Pattison/Majeski, St. Paul Pioneer Press, 1/20). According to the study, Minnesota hospitals reported 99 preventable medical errors, and 30 of the 145 facilities reported at least one medical error. More than 50% of the medical errors reported occurred in surgery, the study found. Minnesota hospitals reported 31 cases in which physicians left foreign objects in patients after surgery and 13 cases in which physicians performed surgery on incorrect body parts, the study found. In addition, Minnesota hospitals reported 24 cases of bedsores, according to the study (Lerner, Minneapolis Star-Tribune, 1/20). The study found that falls accounted for the most deaths related to medical errors. Improper use of, or problems with, medical equipment accounted for four deaths, and medication errors also accounted for four deaths, the study found. The study marks the "first public disclosure of its kind" of medical errors, the Pioneer Press reports. Connecticut and New Jersey recently passed laws that require hospitals to report medical errors to the state, and other states have considered similar legislation, according to NQF (St. Paul Pioneer Press, 1/20).
Reaction
According to the Star-Tribune, "Hospital officials say the disclosures, while painful, are intended to help them learn from each other's mistakes and to improve patient safety." Barbara Balik, executive vice president for safety and quality at Allina hospitals and clinics, said, "I'm sure all of us will be sobered by the report. The way you improve safety is by reporting, learning and then fixing the problems." Alison Page, vice president for patient safety at Fairview Health Services, said, "I don't want to make any excuses for any of these numbers. We're only focused on getting to zero on these numbers, and none of these events should occur" (Minneapolis Star-Tribune, 1/20). Minnesota Health Commissioner Dianne Mandernach said, "The true value of our new reporting system lies not in the numbers but in the underlying evaluation of the causes of the errors and the actions that are taken to prevent them from ever occurring in the future" (AP/Las Vegas Sun, 1/20). However, attorney Chris Messerly said, "The tragedy of the law is that many serious mistakes are not involved in the report. Maybe it's a start. But I hope that (patients) don't bank on it as being full disclosure because it's not even close. It's letting hospitals off the hook" (St. Paul Pioneer Press, 1/20).
The study is available online. Note: You must have Adobe Acrobat Reader to view the report.