Hospital errors on rise, 2018 state report finds

By John Lundy

Forum News Service

Hospital errors rose in the last year across Minnesota, according to the state’s Department of Health’s annual report on the subject.

The Minnesota Department of Health reported 384 “adverse health events” from October 2017 to October 2018, the highest number in the last 10 years. The report, which was the first of its kind in the nation, counts on hospitals to self-report preventable incidents such as falls, pressure ulcers and medication errors.

Those events resulted in 118 serious injuries and 11 deaths during the past year, according to the report.

“This system has given us a much deeper understanding of how and why adverse events occur, and it has helped create a culture of learning and improvement across Minnesota. But despite earnest collaboration and effort, in the last few years of reporting, the number of reported events has plateaued in several categories and increased in others,” state Health Commissioner Jan Malcolm said in a statement accompanying the report. “It is clear there is still more to do to keep patients safe every time they receive care. We look forward to working with our partners this year to ensure this system can continue to improve, evolve and get results.”

Three of the 11 deaths were because of what the report describes as “death or serious injury of a (newborn child) associated with labor or delivery in a low-risk pregnancy.”

Dr. Rahul Koranne, chief medical officer for the Minnesota Hospital Association, noted that 64,000 births occurred in Minnesota during the reporting period.

“These (newborn deaths) are extremely, extremely, extremely rare,” he said.

The number of pressure ulcers rose from 120 to 147, according to the report.

Carrie Mortrud, policy project specialist for the Minnesota Nurses Association, pointed to staffing issues as a possible explanation.

“You need people to turn patients who cannot turn themselves,” Mortrud said. “If you’ve got such short staffing and/or staffing that’s on the bare minimum, and there’s crisis after crisis after crisis after crisis, nurses have to continually reprioritize. … If you had more people around, then these other things could get done when they’re supposed to.”

The number of falls reported statewide dropped from 78 in 2017 to 71 in 2018, according to the report.

Koranne said that in spite of the upward trend in numbers, the state’s performance actually is improving.

He pointed to data showing that “patient complexity” has increased by 20 percent in Minnesota since 2010. Moreover, he said, the rate of adverse health events hasn’t changed since 2009.

The rate both years was 0.006. That is computed by dividing the number of adverse health events by the number of “adjusted patient days,” according to Emily Lowther, a Minnesota Hospital Association spokeswoman.