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Adverse Event Report Shows Good & Bad

Fri, 01/15/2010 - 3:57am

The sixth annual report of adverse health events released by the Minnesota Department of Health saw a patient given the wrong medicine, resulting in serious disability, a woman inseminated with the wrong sperm, serious falls and a patient-against-patient sexual assault. In a knee replacement, surgery on the wrong leg was caught in time, but not before the wrong leg was given regional anesthesia.

In all, four events were at St. Mary’s Medical Center and six at SMDC Medical Center. Five were not preventable, SMDC spokeswoman Beth Johnson said. “There was nothing we could have done differently,” she said. That included the deaths of a diabetic patient from hypoglycemia at St. Mary’s Medical Center and one seemingly healthy patient who died prior to surgery.

In the first case, a hospitalized patient chose to use her own insulin pump, which malfunctioned. In the second, a patient had a fatal reaction to anesthesia that couldn’t have been determined ahead of time, SMDC officials said. “We deeply regret any time a patient dies in one of our hospitals,” said Dr. Jeffrey Lyon, SMDC’s patient safety officer.

Several incidents in one year doesn’t mean a hospital is bad, says Diane Rydrych, a state Health Department spokeswoman who wrote the report. Sixty-two of 200 hospitals and surgical centers reported a total of 301 adverse events from October 2008 to October 2009 – 83 occurred during surgery. “What’s important is they’re finding them, they’re reporting them,” Rydrych said. “They’re shining a light on what’s happening in their facility and they’re learning from them to make sure they’re not happening again.”

At SMDC Medical Center, the case of a woman inseminated with the wrong anonymous sperm has led to a better system of storage to prevent a reoccurrence, said Lyon, who noted that the woman became pregnant but miscarried before she learned of the mistake. It was the first time a wrong sperm/or egg incident was reported statewide since the category was added in 2007.

Rydrych sees this year’s report, showing fewer incidents resulting in death or serious harm to patients, as encouraging. Among the findings:

  • Patient falls resulting in serious disability or death are down 20 percent, with no deaths in 2009.
  • Incidents of pressure ulcers or bed sores were unchanged at 122.
  • Foreign objects left behind during surgery remained constant at 38.
  • Wrong patient, wrong procedure or body part surgeries increased from 39 to 44.

This is an abridged version of an article written by Candace Renalls of the Duluth News Tribune. For the entire article, click here.

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