Hospitals report 20 deaths from mistakes

[TheeBadOne]

Hospitals report 20 deaths from mistakes

Minnesotans now can find out how often their local hospital has serious medical mistakes and patient accidents, but it's not clear yet exactly what the new data means.

The Minnesota Department of Health on Wednesday released -- for the first time ever -- data from the state's 145 hospitals showing the number of medical mistakes that led to ``adverse health events.''

In all, 20 people died and four people were seriously disabled in 99 different hospital incidents from July 2003 through Oct. 6, 2004.

It was the first such reporting period under a new state law approved in 2003.

The numbers include four deaths at St. Luke's hospital and one at St. Mary's Medical Center, both in Duluth. There were no other incidents reported at any other Northeastern Minnesota hospitals. In all, 115 hospitals in Minnesota reported no adverse events.

St. Luke's showed the highest number of deaths in the report. Only three other hospitals in the state -- all, like St. Luke's, among the busiest and most prestigious hospitals in the region -- had more than one death; Fairview Southdale Hospital in Edina with three, and St. Mary's Hospital in Rochester and Abbott Northwestern Hospital in Minneapolis with two each.

The new law, called by one healthcare official as a ``distinct shift in the culture of healthcare'' is considered a first look in the previously shrouded world mistakes and accidents in the health care industry -- problems that often had been resolved in internal reviews or civil lawsuits where the results are not made public.

Minnesota hospitals now are required to report incidents in 27 different medical categories, including falls in the hospital, foreign objects left in the patient after surgery, improper medication, operating on the wrong part of the body, operating on the wrong patient, newborns sent home with the wrong parents, pressure sores, malfunctions of medical products or devices and more.

Minnesota is the first state to require hospitals not only to report the mistakes but to make much of the information public. And because this is the first year of data within the state, there's no track record against which the numbers can be compared.

``One medical error is too many,'' said Dianne Mandernach, Minnesota commissioner of health, in a press conference, adding that Minnesota health care profession ``is doing more than ever before'' to stop preventable errors. ``Does it mean that these are bad hospitals? Not at all.''

Mandernach said she hopes the Minnesota system becomes a model for a national system of reporting hospital mistakes.

Specifics on each case are not made public, nor is any blame or penalty assessed by the state. The problems still are dealt with by internal hospital reviews and are still subject to civil lawsuits. All patients and their families also must be told of any reportable event.

But hospitals are for the first time able to share their mistakes and accidents and, it's hoped, help each other prevent similar problems from reoccurring.

``It's going to improve patient care because it allows us to learn from each other,'' said Dr. Hugh Renier, St. Mary's Medical Center vice president of medical affairs. When care givers analyze what went wrong, that information can be shared with other hospitals. ``We didn't have that ability before,'' he said.

Renier said that any medical mistake or accident is unacceptable, and his hospital's staff won't be happy they made the list with any reportable problems.

But making the information public will increase the public's faith in the health care system, he said, noting medical problems previously have often been shrouded in secrecy.

``Putting the information out there increases the feeling of accountability,'' Renier said.

Jo Ann Hoag, vice president of administration for St. Luke's in Duluth, agreed.

``We believe this is the right thing to do,'' she said, creating a safer environment by reporting problems and learning from them.
St. Luke's officials conceded their death rate from so-called adverse incidents appeared high compared to the statewide total, but they cautioned against drawing conclusions about care. They said St. Luke's may have reported incidents that may not formally have been required.

``We interpreted this new law very liberally,'' Hoag said, not dwelling on whether the hospital was part of the cause. ``If it happened during the stay, we counted it. It will be interesting to see in future years how the statewide numbers change.''

``The report is a snapshot in time,'' said Dr. Gary Peterson, St. Luke's medical director. ``We wouldn't be patting ourselves on the back if we had zero because that can change the next day.''

SURGERY IS TOP PROBLEM AREA

Of the 99 serious problems reported in the state, more than half -- 52 -- occurred during surgery. The most common surgical problem was a foreign object, such as a sponge or needle, being left inside a patient after surgery.

The 31 problems in the next most common category were associated with care management, including medication mistakes, newborn deaths and more.

Other than the 20 people who died and four who were disabled, the other 75 patients -- three-fourths of those involved in the hospital mistakes -- suffered no long-term problems.

State officials warned consumers against directly comparing hospitals based on the reported problems. State officials say the number of incidents may vary because of the size of the facilities, the number and types of surgeries performed and because of different interpretations among hospitals and staffs over what problems require reporting.

State officials joined others in saying the data seems to show the problem is the complex system of healthcare, not poor training or incompetent staff.

``We learned that these lapses are rarely the result of professional misconduct or criminal acts, despite headlines that sometimes suggest the contrary,'' Dr. Kenneth Kizer, president of the Washington-based National Quality Forum, said in a prepared statement. ``Instead, we found that the overwhelming majority of these lapses are unintended consequences of an exceedingly complex and imperfect health delivery system.''

The 2003 law came, at least in part, as a result of a 1999 report by the Institute of Medicine that showed thousands of patients may have been dying in U.S. hospitals each year because of preventable mistakes -- an estimated 44,000 to 98,000 people annually.

That report estimated that drug errors alone killed 7,000 Americans each year, 1,000 more than all workplace injuries.

Many hospital administrators dismissed the 1999 report as inaccurate. And it appears their assessment was correct. Had the Institute of Medicine Report been accurate, Minnesota hospitals would have reported hundreds of deaths during the first reporting period.

Still, because hospital mistakes generally hadn't been made public, or even reported to state regulators in many instances, the public was left in the dark.

Hospital officials in Minnesota say they supported the 2003 law in order to promote public confidence in the state's 139 hospitals, and so that hospitals will take their mistakes to heart and work even harder to correct them.

``The hospitals that are showing up on the list, for whatever reasons, will do whatever they can to make sure they aren't there next year, and that's good for patient care,'' said Bruce Rueben, president of the Minnesota Hospital Association. ``In the future_ it's going to allow the public to measure our success, and that brings accountability.''

Rueben said that some hospital officials were reluctant to support the law, but most now agree it will eventually work to reduce medical mistakes.

``The whole point of this is to improve patient safety. That's the bottom line,'' Rueben said.

He said the sharing of information on the cause of accidents and mistakes among hospitals -- information the public will never see -- is a key element of the new law.

``If there's a medication problem showing up at one hospital, maybe it isn't isolated,'' Rueben said.

For example, Rueben said, when one hospital shared that it had experienced more than one mistaken surgery on the wrong area of the spine, it lead to a new, statewide spine surgery protocol that mandates spinal imaging accompany all spinal surgeries.

Hospitals also are working together to solve problems of bed sores and of pneumonia spurred by ventilators.