Hospital mistakes cause serious injuries
Hospitals in Detroit Lakes and Park Rapids each reported three adverse events in 2012 that resulted in four disabling injuries. Though that number, compared to total patient days, is low, administrators want these reports be a zero-sum exercise. ...
Hospitals in Detroit Lakes and Park Rapids each reported three adverse events in 2012 that resulted in four disabling injuries.
Though that number, compared to total patient days, is low, administrators want these reports be a zero-sum exercise.
At Essentia Health St. Mary's Hospital in Detroit Lakes, a fall was reported that resulted in a serious disability, a medication error resulted in the same, and a surgical procedure "performed on the wrong body part" did not result in serious injury or death.
St. Joseph's Area Health Services reported three incidents that resulted in two serious disabilities.
Both incidents were from falls, the most commonly reported incidents.
A third incident, leaving a foreign object in a patient after surgery, resulted in no serious injury or death, hospital officials reported.
Both facilities have taken aggressive measures to prevent any reoccurrence.
Throughout the state, there were 314 adverse incidents, resulting in 14 deaths and 89 serious injuries.
Minnesota enacted a law in 2003 mandating all hospitals report serious adverse health events. This is the ninth year annual reports were issued through Minnesota's Department of Health.
The local numbers seem to buck statewide trends.
"Retained foreign objects declined by 16 percent," the report's executive summary indicated.
"This is the first decline in this category in five years.
"Medication errors dropped by 75 percent from the previous year and were at the lowest level in all nine years of reporting," the report stated.
A culture of safety and reporting
Last year, St. Joseph's reported one adverse incident. The year before, none occurred. That's about the same record St. Mary's had in Detroit Lakes.
St. Mary's president Peter Jacobson and St. Joseph's Director of Quality Chris Broeker said each hospital's mantra is identical: patient safety comes first and foremost.
"We participate in all the Minnesota hospital patient safety initiatives and those things give us a chance to identify what are of the highest risk for patient safety and identify best practices across the state, learn from each other and each other's events," Jacobson said. Broeker had similar comments.
"When patient safety events occur, we have a reporting system, get all our staff involved in the events that did occur and could occur," Jacobson said.
"Of particular interest," Broeker said, "we've just completed over the last several months is error prevention for the entire staff, mandatory education in strategies and techniques to prevent errors in healthcare. So it's been a priority for our organization."
Both facilities, if a safety incident is reported, immediately launch a "root cause analysis" exercise involving all personnel who might have been involved.
Both facilities thoroughly analyze what occurred and immediately begin a plan designed to prevent future occurrences.
Because the Health Department's reporting system doesn't include punitive measures or name the health care individuals involved, both Broeker and Jacobson say that atmosphere encourages the reporting of incidents and the subsequent analysis.
A state database allows facilities to share information and learn from others' mistakes.
"We track any event that could occur and what we call a near miss," Jacobson said.
"We think it's important to be transparent, to report," Broeker said.
Safety initiative programs "give us a chance to identify what are of the highest risk for patient safety and identify best practices across the state, learn from each other," Jacobson added.
Both administrators are chagrined at the number of incidents that occurred from October 2011 to October 2012, the reporting period. Both vow to improve.
"Is this a significant increase? One is not good," Broeker said. "So we don't want any number of events. Every one is significant."
One of the thorniest issues in the MDH report is the prevention of patient falls, by far the largest hazard experienced by hospital patients.
The MDH report indicates it may be impossible to prevent all falls.
"We would like to think falls are preventable," she said. "We work toward evaluating a patient's risk for falling when they come in to the organization, patients who are at high risk for falls have specialized interventions that are identified."
Jacobson said St. Mary's evaluates each and every patient each shift to determine risks for falling.
St. Joe's conducts a daily "safety huddle" in which all medical personnel discuss patients and their risks.
"If a patient is a high fall risk we have a variety of things that we can put into play," Broeker said.
"One of those is a bed alarm so if the patient gets out of bed, it will alarm and somebody will go and attend to them. In the instance of someone who is confused or not willing to stay in bed we've even gone so far as to put a staff person at their bedside for a certain amount of time to just supervise them."
St. Mary's uses identical methods, Jacobson said.
"We also have a special low bed, lower to the ground," Broeker said. It's important to prevent all falls but the really important thing is to prevent falls with injury."
Both facilities employ the "hourly check" method of checking on patients to encourage help getting out of bed, and making sure their needs are met, even if it's just a glass of water.
Every facility has procedures in place to ensure that a sponge used in a surgical procedure is accounted for.
Two personnel during surgery usually have responsibility for counting sponges, surgical equipment and even wires and miscellaneous objects.
In St. Joe's case, a small metal fragment was discovered in a patient after surgery.
"We do a lot of surgery here," Broeker said. "Sponges are counted before and after procedures. A piece of metal from one of the instruments could break off.
"Counting before and after and making sure the surgical field is being observed" is a common practice, she said. "Making sure that needles that go in are needles that come out. The surgical assistant and circulating nurse are counting and observing in surgery all the time."
In St. Mary's case, "a surgical procedure was done," Jacobson said. "The incorrect joint on a foot was fused. And we did a root cause analysis. Normally you would use fluoroscopy for that procedure so we've added a checklist to prevent that from occurring in the future and we've also added an additional fluoroscopy unit to make sure they're readily available."
St. Joseph's has 25 beds; St. Mary's has 41.
St. Joe's performs 11,152 surgeries per year, according to the report. St. Mary's performed 12,831 during that reporting period. It's a lot to keep track of.
Redundancy is key
From the moment a patient enters a facility for any procedure, said St. Joseph's communications director, a redundancy ensues.
"We have a culture of encouraging each other to ask questions," said Judith Miller. "And that really helps confirm and affirm as well as avoid adverse occurrences.
"You might be asked the same question any number of times," she said.
"At every juncture, just to verify who you are and reconfirm what you are there for. If you're having surgery it is reconfirmed many times as to the site, which leg, which spot and those are all practices we have in place. We confirm and affirm with the patient. 'I'm asking you this because...' So everyone is practicing the same safety-first skills," she said.
And she admits it can frustrate patients, but it's a far sight better than removing the wrong toe.
The full report issued by the Minnesota Department of Health is posted with this article at www.parkrapidsenterprise.com .
(Sarah Smith writes for the Park Rapids Enterprise)