Report notes errors in care

FAIRMONT – For the past nine years, Minnesota hospitals have been required by the state to report serious “adverse health events” and analyze the cause.

Categories and number of events occurring across the state include:

o surgical/invasive procedures, 84;

o products or devices, 4, resulting in 2 deaths;

o patient protection, 6, resulting in 4 deaths;

o care management, 132, resulting in 1 death;

o environmental, 84, resulting in 7 deaths;

o criminal, 2.

“These are events that in the ideal world would never occur in our organization,” said Dr. Steve Campbell, a family physician and chief medical officer for Mayo Clinic Health System, who spoke with reporters Wednesday.

Three Mayo sites in the region reported 10 events in 2012, an increase from the two events reported the year prior.

Those facilities include Fairmont, where a fall occurred that resulted in a serious disability, and a foreign object was left in a patient after surgery.

At Austin’s medical center, an incorrect surgical procedure was performed. In Mankato, there was one foreign object left in a patient after surgery; three falls, one resulting in a death and the other two causing serious disabilities; and two pressure ulcers, or bed sores.

“The increase in events … doesn’t necessarily mean care is getting worse,” Campbell said. “I want to emphasize the reporting structure is improving, and staff are more comfortable reporting when things don’t go well.”

According to Campbell, Mayo has made a systematic effort to encourage staff to report incidents as they occur, attempting to move away from an intimidating old-school hierarchy and the “shame-and-blame perspective.”

“We specifically looked at fear of speaking up,” he said. “… Throughout health care, internationally and nationally, that is a topic of a lot of interest.”

By investigating incidents promptly, they are better able to look at the root cause and ultimately implement solutions.

“Any event we take seriously, and the vast majority of events we do learn something from them,” Campbell said.

For instance, after seeing that retained sponges following a surgical procedure was among the most common adverse health event being reported, many hospitals implemented a bar-code system on sponges. Mayo Clinic Health System has not had any such incidents since it began bar-coding sponges mid-2012.

Mayo also has introduced new standards to prevent other adverse health events, including its assessment of a patient’s risk of falling and how that information is shared between staff members.

“Since that time, we have had zero deaths,” Campbell said.

The report, Adverse Health Events in Minnesota, is being released today by the Minnesota Department of Health. It can be viewed online through a link available at

In addition to alerting consumers of incidents that have happened at their health care facilities, Campbell described a couple ways the information is helpful to the participating facilities: It gives them a benchmark against other organizations across the state, and it gives them an opportunity to connect and share ideas for solutions.

“We’re really fortunate we live in a collaborative state,” he said.