Study: Minn. reporting system cuts hospital errors

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MINNEAPOLIS (AP) — Deaths and other harm to patients from preventable errors such as falls and surgical mistakes have dropped in the 10 years since Minnesota started requiring hospitals and other care centers to report them, according to a report released Thursday.

But the Minnesota Department of Health also said in a related annual report that patient deaths did not decrease in 2013. And patient falls have been particularly difficult to eliminate, the report said.

The department said the 10-year lookback shows encouraging progress under the state's Adverse Health Care Events Law. The law requires hospitals and ambulatory surgery centers to report 29 types of incidents, including bed sores, falls, foreign objects left inside a patient after surgery, surgery on the wrong body part, medication errors and suicides. The law also requires studying how the mistakes happened.

"The AHE law was a catalyst for patient safety throughout the state," the department's 10-year evaluation report said. "It has helped bring patient safety to the forefront, increases awareness, and led to focused patient safety activities."

Health Commissioner Ed Ehlinger called the preventable mistakes "a wicked problem" because their causes are complex and reducing them requires aggressive efforts. But he said the reporting requirements have helped change old expectations that errors were just part of the price of doing business.

"We've really been able to bend the curve and start to reduce the number of deaths and the number of disabilities that have occurred in hospitals," Ehlinger said. "And our hospitals are safer than they were 10 years ago. They're safer because the hospitals have really taken on safety as part of their culture, from the top down, from the head person to the people on the floors."

Deaths from preventable errors declined from a high of 25 in 2006 to a low of five in 2011, according to the report. But the number bounced back up to 14 in 2012, and to 15 in the 2013 reporting year, which ran from October 2012 to October 2013. Ten of those deaths were related to falls.

The annual report said such falls happened despite significant efforts by health care facilities, as well as a safety alert for preventing falls that the health department and Minnesota Hospital Association issued last May.

Total adverse events reported in 2013 were 258, down 18 percent from 2012, driven mostly by a 35 percent decline in pressure ulcers, also known as bed sores. Surgical errors, including wrong-site operations and objects left in patients, fell from a high of 89 in 2011 to 61 in 2013.

Ehlinger said the hospitals and surgery centers performed 2.6 million procedures in 2012, and in many cases the people who suffered errors were elderly with other risk factors such as dementia or brittle bones, or were on anticoagulants to prevent strokes. He said their deaths are tragic but not surprising.

"They are preventable and our goal is to get them down to a zero level, but the reality is that we probably will never reach that goal," he said.

The 10-year evaluation from the state Health Department recommended more education and training opportunities, better data sharing and more encouragement for providers to adopt best practices in patient safety.

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