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Report outlines adverse events at Minnesota hospitals in 2008

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After a patient at Chippewa County-Montevideo Hospital died by suicide last year, a hospital team sat down and analyzed what happened and how corrective action could be taken to prevent it from happening again.

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The process "definitely" was helpful, said Mark Paulson, the hospital's administrator.

"It causes us to revisit existing policies and procedures and extend ourselves to look beyond what we're currently doing," he said. "Our highest priority is the care and safety of our patients."

The patient death was among 312 adverse events, ranging from wrong-site surgeries to serious medication errors, that were reported at Minnesota hospitals last year. There were 18 deaths and 98 serious disabilities.

The Minnesota Department of Health released the annual report Friday. This is the fifth year that hospitals, surgery centers and behavioral health hospitals in Minnesota have been required to report any of 28 so-called "never" events, analyze what went wrong and come up with a corrective plan.

Because legislation in 2007 expanded the types of events that must be reported, the number is up this year. Last year it was 125.

Health care facilities now must report patient falls that result in serious disability, as well as falls that are fatal. They also must now report pressure ulcers that cannot be staged into one of four categories. If these requirements had not been added, the number of adverse events reported for 2008 would have been 141.

Four area hospitals are among the 59 facilities where a reportable event occurred last year.

Appleton Area Health Services in Appleton and Meeker Memorial Hospital in Litchfield each reported one case in which a foreign object was left inside the patient after a surgery or other procedure. Neither resulted in death or injury.

Granite Falls Municipal Hospital and Meeker Memorial Hospital each reported a patient fall that resulted in serious disability. This category became reportable last year.

Chippewa County-Montevideo Hospital reported one patient death due to suicide. It was the first time since the adverse event reporting law went into effect five years ago that the Montevideo hospital has had a reportable event, Paulson said.

For the second year in a row, Rice Memorial Hospital did not have any adverse events that reached the threshold of being reportable. The Willmar Surgery Center did not have any reportable events either.

Dale Hustedt, interim chief executive officer at Rice Hospital, said serious adverse events are tracked carefully at the hospital.

"Our goals are to have no reportable events," he said.

To have been successful two years in a row is "significant," he said. "It speaks of the quality we've got here."

Overall, adverse events are still rare compared to the number of hospitalizations and procedures that take place in Minnesota each year. In 2007, Minnesota hospitals had nearly 2.6 million patient days and nearly 9 million outpatient registrations. Same-day surgery centers had nearly 190,000 registrations.

Statewide, the most frequently reported adverse events last year were pressure ulcers, falls, and foreign objects left inside the patient after surgery.

State health officials say that by openly sharing information, hospitals can learn from adverse events and take steps to improve patient safety.

This year's report found that the majority of hospitals are placing a higher priority on patient safety than they did five years ago. More hospitals are changing their policies and procedures -- for instance, a team approach to preventing errors such as wrong-site surgery is now much more widespread.

"I think what has made this process so valuable for us is it allows us to look into what other organizations are doing," Hustedt said. "That has been a huge step forward, I think, in safety for patients at Minnesota hospitals."

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