Preventable errors double in Minnesota hospitals in past decade

Preventable errors have nearly doubled over the past decade in Minnesota hospitals, where staffing shortages and other pressures have left patients more vulnerable to disabling falls, assaults and surgical and laboratory mix-ups.

The 610 adverse events in the 12 months ending last October remain rare, considering that Minnesota hospitals perform roughly 567,000 surgeries and procedures each year. Still, health care leaders said they are troubled by the increase post-pandemic.

Sixteen patients died last year from reportable events, such as medication errors or device malfunctions, while another 222 suffered disabling injuries.

Hospitals might need to go "back to the basics" and recommit to longstanding safety practices, said Rachel Jokela, director of the Minnesota Department of Health's adverse event surveillance system, which allows people to look up error totals by hospital.

"With anything ... we do all the time, it just becomes so automatic that you might drift a little bit. You might not be paying as close attention," she said.

The reporting system was a national pioneer when it was started 20 years ago. Publicizing medical errors helped usher in changes at hospitals, such as marking in ink incision sites for surgeries to prevent operations on the wrong body parts. Hospitals also shared lessons to prevent others from making similar mistakes.

Reviews of recent adverse events show those safety efforts don't always work. The state reported 25 wrong-site surgeries last year despite the site marking protocols. Sometimes, Jokela said, clinicians marked the operation sites from memory, without the required verbal verifications or the double-checking of written records.

Inattentive counting during surgeries also contributed to a record 42 incidents in which sponges and other items were left inside patients. Items in some cases were intentionally left in patients during their recoveries, but then hospitals forgot to remove them.

Hospital leaders had hoped their safety efforts reached a turning point in 2019, when 366 reportable adverse events represented a rare annual decline. COVID-19 disrupted that progress, though, and errors have surged.

Minnesota also reported a record 25 medication errors, which contributed to 22 serious injuries and three deaths, despite the routine use of barcode scanners to match prescription medications with patients' wristbands. The errors mostly occurred at the times drugs were administered, but some errors resulted from bungled prescriptions or transcriptions into patients' medical records. Almost one in five involved the wrong drug. One in three resulted from the wrong dosage.

"So the barcode won't help you there," Jokela said, "because the barcode on the medicine will match the patient."

M Health Fairview reported six medication errors across five Twin Cities hospitals, including one patient death. CentraCare reported four across three hospitals in central Minnesota.

The Minnesota Hospital Association in a statement said its doctors and nurses are stretched thin, partly because a shortage of discharge options such as rehab centers leaves hospitals stuck with patients no longer needing inpatient care. The patient backlog cost Minnesota hospitals an estimated $480 million last year and also distracted clinicians from focusing on incoming patients with pressing medical needs, the association said. Doctors in some cases provided inpatient care to patients stuck in emergency rooms, and that change in environment increased the risk of errors.

"The impact of discharge delays isn't just financial," said Jennifer Schoenecker, the hospital group's associate vice president for quality and safety. "Patients are also paying the price."

Increases in prior years sometimes reflected new categories of errors that the state added, or new hospitals or outpatient surgery centers reporting data for the first time. Not this year. Hospital leaders said significant shifts within their facilities are presenting new challenges.

Patients are getting older and sicker, and staying in inpatient beds for five days on average rather than four, increasing the risk of pressure sores. The state reported 284 of these wounds, which occur when bedbound patients aren't repositioned and their skin suffers prolonged pressure or friction. Among last year's reported cases, 31 caused disabling injuries while others required treatment or monitoring. Many occurred when patients' skin rubbed against medical devices or tubes.

Some hospitals have been more aggressive in reporting bed sores, which limits the use of the data when comparing providers on their safety records. Methodist Hospital in St. Louis Park is Minnesota's ninth-largest hospital by bed capacity, but its 52 adverse events last year were surpassed only by Hennepin Healthcare's 59 and Mayo Clinic's 53. Methodist's report included a disabling burn, two severe medication errors, a serious injury to a newborn in a low-risk pregnancy and 37 bed sores that required treatment or monitoring but didn't cause serious injuries.

The state also reported 96 fatal or disabling patient falls, which can reflect a shortage of nursing staff and aides to monitor and help frail patients. Many of the falls involved patients who didn't wait for help or misjudged their strength when trying to walk to the bathroom.

The 16 patients or workers seriously injured by physical assaults last year also reflected a shifting reality in hospitals where delirious or confused patients can become combative, or distraught relatives or visitors can lash out. Minnesota reported 14 such assaults in 2022, but no more than seven in any prior year.