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Mayo Clinic Health System in Austin reports 1 error in annual survey

Mayo Clinic Health System in Austin reported one medical error resulting in serious disability in fiscal 2011, according to a Minnesota Department of Health report released today.

That incident, which wasn’t detailed in the report, was the only error reported out of 15,037 surgeries or invasive procedures performed between Oct. 7, 2010 and Oct. 6, 2011. Mayo Clinic Health System in Austin’s report includes its clinics in Grand Meadow, LeRoy, Adams and Blooming Prairie.

The hospital, which performed 15,024 surgeries in fiscal 2010, reported one “wrong surgery” that year, although it did not result in serious disability or death. The hospital reported no errors in 2009 or 2008.

Diane Twedell, vice president of operations at Mayo Clinic Health System in Austin, said the hospital continually learns from its mistakes and strives to improve every year.

“I think every year we learn more, and every year we find new ways to make things safer,” she said. “Having this report is very good for Minnesota and for our patients.”

Twedell said patient safety is “truly the highest priority,” and they truly regret every instance of harm.

“When we have an adverse event, it’s not just a statistic. It affects real people and real families,” she said.

Twedell said they would prefer to have zero mistakes, but they always encourage staff to be as transparent as possible.

Mayo Clinic Health System in Albert Lea reported one “retention of a foreign object in a patient after surgery” in 2011, although it didn’t result in serious disability or death. That was the only incident reported out of 14,738 surgeries.

Mayo Clinic in Rochester, which performed 279,620 surgeries in 2011, reported 57 errors resulting in three disabilities and one death.

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.

Serious mistakes across Minnesota hospitals rose slightly in 2011, but they led to fewer serious injuries and deaths than the year before.

Hospitals reported 316 so-called “adverse health events,” up from 305 the year before. Eighty-nine of the incidents resulted in serious injury or death, down from 107 the year before and the lowest number since 2007.

The report determined that the overall increase in mistakes was due to more pressure ulcers — commonly known as bedsores — and “wrong procedures” performed on patients. Wrong procedures occurred 26 times, a 63 percent jump.

Lawrence Massa, president and CEO of the Minnesota Hospital Association, said the mistakes can occur because of miscommunication between clinics and hospitals during the scheduling of surgeries and other invasive procedures. He said hospitals are increasingly adopting the World Health Organization’s Surgical Safety Checklist, a series of preventive steps before each surgery, including a “time out” to identify the patient and procedure before picking up any instruments.

But health officials trumpeted improvement in other areas: serious falls dropped 11 percent and wrong-site surgeries were down 23 percent.

“We were very pleased to see that the overall level of harm that was reported … was down, even though the total number of events was up,” Massa said.

Pressure ulcers made up the largest share of the medical mistakes: 141, a 19 percent increase from the year before.

Though they may seem minor, pressure ulcers can lead to infection, prolonging hospital stays and taking a long time to heal, said Dr. David Bates, director for the Center for Patient Safety Research and Practice at Brigham and Women’s Hospital in Boston. But they remain a universally stubborn problem for many hospitals, he added. At Mayo Clinic in Rochester, 41 of the 57 mistakes were pressure ulcers.

“The issue is that patients who are immobile are at risk for developing pressure ulcers. Yet it’s hard to tell who is really having problems with moving,” Bates said.

—The Associated Press contributed to this report.