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Minn. hospital mistakes rise in Department of Health annual report

DULUTH—A sexual assault on a patient in Hibbing is among 341 "adverse health events" that occurred at Minnesota hospitals and surgical centers between October 2016 and October 2017, according to an annual report released Thursday, Feb. 22.

The events ranged from falls resulting in serious injury to pressure sores to "surgery/other invasive procedure performed on wrong patient," according to the report compiled by the Minnesota Department of Health.

The statewide number of the 29 categories the state tracks was up for the fourth straight year, noted state Health Commissioner Jan Malcolm in a news conference.

"This steady rise in reportable adverse events is concerning, and we should not consider this acceptable," Malcolm said. "We can, and must, do better as a community to improve patient safety."

It's the 14th year the report has been compiled and released to the public. The errors resulted in 12 patient deaths, the health department reported.

The sexual assault in Hibbing, one of three recorded in the state in which a patient was the victim, occurred at Fairview Range Medical Center.

In a statement, Fairview declined to comment on the specifics of that event, citing patient privacy.

"However, patient safety is and must be our highest priority," the statement continued. "While incidents involving patient safety concerns are rare, each one is taken very seriously. We follow an immediate and robust process to learn exactly what happened and create solutions to prevent future incidents."

Rachel Jokela, who directs the adverse events program for the health department, said during the news conference that often when such assaults occur the assailant also is a patient. The most common settings are in behavioral or mental health units, she added.

Dr. Rahul Koranne, chief medical officer for the Minnesota Hospital Association, said in a separate interview that it's difficult in a hospital atmosphere to completely prevent all possible misconduct.

"Hospitals and health care facilities are not jails," he said. "There is no way to lock up a patient so that they do not have access to other patients."

Falls were the second-most common category listed in the report, after pressure ulcers. Only falls resulting in serious injury or death are included in the report, although hospitals track all falls, said Dr. Rajesh Prabhu, patient safety officer for Essentia Health in Duluth.

Every fall at every Essentia Health facility is reviewed to determine what could have been done differently, Prabhu said. In addition, the health system within the past year instituted a daily 15-minute "huddle" to discuss any safety-related events that occurred during the previous 24 hours.

In the news conference, Malcolm noted an increase in the number of incidents involving surgery or invasive procedures. "This category ... needs renewed focus," she said. "We know that in a significant percentage of these cases, an effective 'timeout' and verification of the surgical site was not done."

A "timeout" is when a surgical team comes to a full stop ahead of an operation to make sure the surgical site is known, the procedures are understood and that everyone is on the same page.

This time around, 55 incidents involved wrong surgeries, wrong-site surgeries and left or retained objects, Malcolm said.

Minnesota is one of only five states that reports such data to the public, she said.

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