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Preventing Medical Mistakes 2.0

February 11, 2013 By Aaron Sinner, Policy Associate

The Minnesota Department of Health is out with its annual report on Adverse Health Events. Sometimes referred as “never event” errors, as in mistakes that should never occur, these medical events include severe bedsores, serious patient falls, surgical sponges left inside a patient, and surgeries performed on the wrong side of a patient’s body. The report includes 28 adverse health events in all. Through the awareness the report raises, particularly among the medical community, the report serves to improve care across the state and create a culture emphasizing patient safety.

This year’s report found 14 deaths and 89 serious injuries resulting from adverse health events in 2012, numbers which have risen since previous years. However, that rise isn’t particularly significant for many reasons. For one, much of that rise is likely driven by hospitals improving their reporting standards for these events in the decade since the reporting requirement was implemented. For another, this year’s numbers underscore how truly rare these never events are, showing 12.1 events per 100,000 days a patient stayed in a hospital—and with numbers so small in a sample size so large, minor increases are often nothing more than statistical blips.

Rather than year-to-year or facility-to-facility comparisons, the report’s greatest use is in the attention it draws to the problem of adverse events and the reminder it provides that these events are preventable. "It’s not okay if Grandma falls in the hospital and seriously hurts herself," as Marie Dotseth, Executive Director of the Minnesota Alliance for Patient Safety (MAPS) puts it.

Since the legislation creating the annual report passed in 2003, the Adverse Health Events report has helped reshape the medical landscape in Minnesota toward a culture of patient safety. The report has helped reinforce to hospitals that events like bed ulcers and falls aren’t simply periodic occurrences but are preventable problems. “The report raises the awareness that these things are preventable and encourages hospitals to look around the state and country for best practices,” says MAPS Project Manager Kate Kepple.

For instance, it's now commonplace for medical teams to count the sponges used in baby deliveries to ensure they are all accounted for following the procedure, a practice that was not always the norm before the report.

One way the report creates these outcomes is through simple peer pressure. “Providers don’t like to compare unfavorably to their competitors,” Dotseth says, which has accelerated the implementation of best practices for preventing many of these events.

A decade after the creation of this annual report, the information it has provided on patient safety also points the way toward other possible health reforms. In a recent report, Minnesota 2020 suggests requiring hospitals disclose broader measures of patient care than just adverse (or never) events, such as cases of in-hospital infection and rates at which patients are readmitted to a hospital within 30 days of initial discharge due to complications. Additionally, the Affordable Care Act that became federal law in 2010 includes Medicare reforms which pay hospitals less if they have high readmissions rates.

MAPS has begun exploring ways to create more multi-dimensional patient safety reports. “We don’t have a good report in this state or country for measuring implementation of patient safety best practices. MAPS has begun to ask, ‘Is there some kind of way to better aggregate this data to better keep track of patient safety progress?’” says Kepple. With events as rare as these never events, outcomes-based metrics often fail to paint the whole picture, and can be subject to the random flukes and spikes found in statistically small samples. MAPS also wants to broaden the conversation from hospitals to include long-term care facilities and clinics.

Kepple does point out one danger in developing further measures of patient safety for hospitals to report is that hospitals will encounter “metric fatigue.” The time and effort required to record and report safety metrics pulls resources away from patient care itself. It’s an important balance that needs to be struck when considering any further reporting on patient safety.

And, as Kepple says, “We need to do a better job of putting the information in patients’ hands, but it’s also true that some of this information doesn’t lend itself well to that.” She points out that patients often have little say in which hospital they utilize, so safety information is often at its most useful for the medical industry itself. Public reports are ultimately a means to the end of reforming hospital practices and creating better incentives for hospitals to prevent poor patient care.

In the meantime, the annual release of the Adverse Health Events report helps remind us all of the road we’re on toward patient safety.

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  • Ginny says:

    February 12, 2013 at 11:18 am

    A little over a year ago, my 97-year-old mother fell out of her bed at North Memorial Hospital, a fall that ended in her death. The staff had forgotten to put up the bed rails after she was up the previous time. They knew she was always trying to get out of bed and come home with us.
    At that time, we had already agreed to stop all her meds except the ones that made her comfortable, so her death was already imminent. But what this meant for us is that since she had broken her hip she was under heavy morphine or whatever until she died a few days later, preventing any of us from any further communication.
    I wrote to the hospital and got a nice letter back with assurances they were working to improve it all. I had no intention of taking further legal action—I knew that would be difficult, expensive, and maybe impossible. But I couldn’t find a state agency to report it.
    This was such a preventable error. The death certificate gave the fall as the cause of death. It’s heartbreaking for everyone involved.