Archived Story

Clinic reports single medical error last year

Published 4:13pm Saturday, February 9, 2013

Mayo Clinic Health System – Albert Lea and Austin reported one medical error in 2012, according to the Minnesota Department of Health.

Out of 12,673 surgeries done from October 2011 to October 2012, Mayo employees performed one incorrect lens implant during eye surgery, a Mayo spokesperson said. The surgery did not cause a serious disability.

Statewide, Minnesota hospitals reported 314 adverse health events, or medical errors, according to MDH’s 2013 Adverse Health Events in Minnesota report. That’s about the same as the 316 errors reported to the state in 2011. Medical professionals made fewer mistakes in retaining foreign objects inside patients, causing pressure ulcers — commonly known as bed sores — or medication errors. Yet hospitals reported more injuries related to patient falls this year, and MDH is calling for further training on suicide prevention and violence. Four people committed suicide in Minnesota hospitals last year, and two more suffered serious disabilities from attempting to kill themselves.

“Any event is one event too many. Our goal is to never have any events,” said Jodi Schulz, Mayo Clinic Health System’s patient safety officer for southeastern Minnesota. “Each event that we have, we look at why the event occurred, so that that won’t happen again.”

Schulz said adverse health events were up system-wide this year, primarily due to more patient falls and fall injuries. As a result, Mayo Clinic Health System officials will find ways to reduce the amount of falls patients have this year.

Schulz said hospital workers make sure to check on patients every hour to reduce a patient’s need to get up on their own. In addition, hospital workers assess each patient daily to see how likely patients are to fall and suffer injuries. Each incident is reviewed by hospital staff and by system officials, according to Schulz.

State law requires hospitals and ambulatory surgical centers to report serious mistakes and investigate why they happened. The report examines potential errors in six categories: Surgical, environmental, patient protection, care management, product and device, and criminal events.

“Wrong procedures” differ from wrong-site surgeries, in which surgeons may, for example, mistakenly operate on a patient’s left leg when the right leg was the target.

The report noted improvements in some areas. The total number of pressure ulcers declined from 141 in 2011 to 130 last year; the number of retained foreign objects declined for the first time in five years, by 16 percent; and medication errors dropped by 75 percent to the lowest in the nine years the state has been tracking adverse events.

This is the ninth year that the state has reported adverse health events. Although a few other states now issue annual reports, Minnesota still is the only state that reports individual hospitals’ numbers, said Diane Rydrych, director of the Health Department’s health policy division.

The report doesn’t name the personnel involved in the mistakes.

—The Associated Press contributed to this report.

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