The Minnesota Department of Health has released its report on "adverse health events" in Minnesota hospital between October 2016 and October 2017.
For adverse health events, read "preventable errors" that in some cases lead to serious injury or even death.
In that 12 month period, there were 341 adverse health events in Minnesota hospitals, the highest seen since a number of new errors were added to reporting statistics in 2014.
Of these, 103 resulted in serious injury and 12 led to deaths – much higher than the 4 seen a year earlier, but lower than any of the four years before that.
What errors caused deaths?
Of the 12 deaths caused by preventable hospital errors, five of them were falls.
Falls were the second most common adverse event in 2016-17, with 82 incidents reported in total. The only event with more was pressure ulcers with 120.
Of the 7 other preventable deaths, two were caused by a product/device air embolism – a complication of surgery – two were the deaths of newborns despite low-risk pregnancies, one mother died in childbirth, one from a suicide, and one the result of incorrect medication.
More than half of fall-related injuries or deaths happened on adult medical or surgical wards, with 14 percent in the emergency department.
Around a quarter of these falls involved patients recently diagnosed with delirium or dementia, which are a risk factor in falls.
Surgical errors account for 82 events in 2016-17, which covers things like being operated on the wrong body part, a member of the surgical team leaving a foreign object inside a body, and someone undergoing the wrong procedure.
The number of "wrong site" (wrong body part) surgical events hit the highest level in recent history with 36 incidents, though this is out of more than 3.1 million surgeries and invasive procedures carried out in the state last year.
The most common kind of surgery where errors occurred were during spinal injections/procedures, or pre-procudural injections (such as anesthesia).