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Medical Mistakes In Minn. Hold Steady At 305

MINNEAPOLIS (AP) -- Minnesota hospitals showed no improvement in reducing the number of serious medical mistakes last year, according to a new report from the state Department of Health, which disappointed some experts who hoped for a drop.

The department's annual report released Thursday said there were 305 reported mistakes -- including 10 that led to death -- from October 2009 to October 2010. There were 301 reported mistakes the year before.

"Most of these events are preventable," said Diane Rydrych, assistant director of the department's health policy division. "Holding steady is not good enough."

The document was compiled from reports by hospitals, outpatient surgical centers and community behavioral health hospitals of "adverse health events," which range from bedsores, to surgery on the wrong body part, leaving foreign objects in bodies and suicides. It does not describe individual cases.

Lawrence Massa, president of the Minnesota Hospital Association, said his group has worked hard for years to reduce the number of medical mistakes by encouraging hospitals to share and adopt their best practices. "We're disappointed that we're not seeing the numbers come down," Massa said.

The report shows that medical mistakes remain uncommon in Minnesota hospitals, but Massa said that's not the point. "These are very rare events, but we've taken the position that one is too many," he said.

As in past years, bedsores and falls remain the most frequently reported adverse events. There were 122 reports of bedsores or pressure sores, about the same as the 118 reported the year before. There were 80 reported falls, nearly the same as the 76 reported the previous year.

Of the 305 cases, there were 10 that resulted in death -- up from four the year before -- and 97 in which the patient was seriously hurt. The number of serious injuries also held about steady from last year's report.

Of the mistakes that led to serious injury, about 75 percent were caused by falls. Rydrych said one pattern that emerged from the latest data showed hospitals need to do a better job ensuring patients ask for help moving around their rooms.

"A lot of the patients who fall, fall making their way to the bathroom," she said. A problem has been patients who initially ask for help, but then overestimate their recovery and fall later in their hospital stays.

The report indicates doctors in Minnesota either operated on the wrong site or did the wrong procedure 31 times last year. In more than a third of the cases, the surgical teams failed to locate and verify the mark indicating where the surgeon should work.

There also were 34 cases of foreign objects being left in a body, typically small sponges or the tips of instruments that broke off during a procedure. The report attributed some cases to simple human error, but also faulted medical teams for failing to account for surgical items before and after the procedure.

Rydrych said hospitals may never eliminate all falls and pressure sores, but operating on the wrong body part or leaving surgical supplies inside a patient shouldn't still be happening.

Dr. James Reinertsen, a national safety expert who has worked with the department, attributed the scant of progress on reducing medical mistakes to a lack of will among hospital leaders.

He said hospitals around the country that have reduced medical mistakes have no tolerance for hospital staff failing to follow safety procedures. Reinertsen compared it to the airlines' approach to pre-flight checklists.

"If a pilot says, `You know, this checklist thing is fine, but I don't think I'm going to use it', they would lose their job that day. Not two years from now, that day," Reinertsen said. "I think that's what will looks like when you get serious about safety."

(© Copyright 2011 The Associated Press. All Rights Reserved. This material may not be published, broadcast, rewritten or redistributed.)

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