The number of mistakes hospitals made increased slightly last year, but the number of deaths as a result of those errors declined, according to the Minnesota Department of Health.
The department's Adverse Health Event report is meant to track errors to help medical professionals improve patient safety, with the goal of achieving zero mistakes.
Last year (October 2013 to October 2014), the 69 Minnesota hospitals and surgical centers included in the report saw more than 2 million visits and reported 308 errors, including 98 serious injuries and 13 deaths.
Looking at the numbers
The number of errors was higher this year, due in part to the addition of four new reportable event categories, but there was an improvement over the number of deaths recorded in last year, which saw 258 events, 84 serious injuries and 15 deaths from October 2012-October 2013, MDH said in a news release.
Falls are the most dangerous incident
As with previous years, falls were the event most likely to cause serious patient harm or death.
There were a total of 79 incidents in which a fall resulted in serious patient injury, including six deaths. Medication errors and neonatal events were also among the events most likely to cause serious harm or death.
Incidents of falls, pressure ulcers and wrong-site surgeries have declined. But other errors, including incorrectly placed catheters and feeding tubes, have increased slightly, MPR News reports.
Minnesota is one of 28 states that tracks adverse health events, and is one of three that publicly reports the data, MDH notes. Since the state began tracking mistakes in 2003, hospitals have improved their safety records, MPR says.
With most of the mistakes made in this year's report, medical professionals were able to pinpoint the root cause of the error – most weren't related to patient care, but due to communication problems. Hospitals' policies/procedures and training/education also played a significant role in many of the mistakes made.
Goals for this year
MDH hopes to improve on the following for 2015:
- Test strategies to reduce lost or damaged biological specimens – there were 20 instances in this year's report in which an irreplaceable lab specimen was lost.
- Improve communication with test results, which resulted in four serious injuries and one death in this year's report.
- Be more effective identifying fragments or instruments and wires to reduce the number that's left in patients – there were 33 instances in which objects were left in patients.
- Improving perinatal safety – there were six instances of neonatal death or serious injury during a low-risk pregnancy, including four deaths.
- Partner with surgeons and interventional radiologists to improve correct spine level surgery and spinal injections.