Healthcare News & Insights

Adverse medical events: Are hospitals lowering their numbers?

It would appear that hospitals have more work to do when it comes to lowering the number of adverse medical events that occur. One state in particular isn’t very happy with its hospitals’ and surgery centers’ progress.

After nine years of owning up to mistakes, Minnesota’s latest annual report on adverse medical events shows its hospitals and surgery centers numbers aren’t getting better: 75 hospitals committed 314 reportable errors in the 12-month period ending Oct. 6. — 14 involved patient deaths and 89 resulted in severe injuries. The previous year 316 errors and five deaths were reported.

It’s frustrating for hospital executives who’ve been incorporating comprehensive reforms to eliminate preventable mistakes. It just goes to show that even if procedures are put in place, they won’t make a difference if they aren’t followed.

“We’re still at a level that is too high,” Dr. Ed Ehlinger, state health commissioner, told the StarTribune. “These are things that shouldn’t be occurring.”

Time outs

Even when mandatory “time outs” — pauses when surgical teams verify they’re about to do the right procedure on the right patient — are involved, four out of five mistakes involve the wrong procedure or wrong body part.

Reason: Hospital workers can lose focus, especially when they’re in a hurry, and often they don’t understand the time-out process.

A doctor is supposed to mark the site of a procedure in ink and have the patient initial it. Then the doctor is supposed to review that mark one last time, but it doesn’t always happen. These procedures are put in place for a reason and they have to be followed for mistakes to be avoided.

“If the site mark is not visualized during time-out, and a team member relies on memory, that’s a problem,” Kathleen Harder of the University of Minnesota’s Center for Design in Health told the StarTribune. “If that step is missed — and I have seen it missed — then wrong-site surgery can occur.”

Harder was dispatched by the Health Department to observe hospital time-outs throughout Minnesota.

Getting it right

In Minnesota last year, eight of the 30 wrong-procedure cases involved implanting incorrect ocular lenses in patients’ eyes. But the Phillips Eye Institute in Minneapolis, hasn’t had a mistake like that since 2008.

Why?

Because leaders at the facility audit one in 20 procedures to make sure time-outs are done properly, and they make surgical teams do it over if they aren’t done properly. In addition, the institute implemented a step-by-step procedure for avoiding such mixups.

It worked so well that the state urged all hospitals to adopt Phillips’ safety procedure. And since they have, there haven’t been any incidents of incorrect-lens cases.

 

 

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