Dr. Gary Peterson, chief medical officer of St. Luke’s, said each event is treated seriously.

“I’d like to say how sorry we are at St. Luke’s for any adverse events happening at our hospital and how seriously we do take those events,” Peterson said. “We have a number of initiatives that we’ve undertaken here at St. Luke’s … to really focus on those areas that are causing significant harm.”

Lyon, who sits on the patient safety committee for the Minnesota Hospital Association, expressed similar views.

“Behind those numbers are actual people who have come to some type of harm … while patients at our hospitals,” Lyon said. “There’s nobody here who takes any pleasure in that at all. This is a report of the failures that we’ve had … and we want to take that bad news and try to do good things with it.”

Each event has its own story. An incident with a foreign object occurred when a temporary device that had been implanted was removed from the patient’s body but a small piece of plastic tubing was left behind, Lyon said. It was removed later under local anesthesia.

A wrong procedure occurred when a joint was drained instead of the cyst next to it, he said. The wrong patient was treated when a doctor filled in the right order on the wrong patient’s chart.

Statewide, the biggest increase in adverse events was pressure ulcers, an increase by 19 percent to 141. Carol Diemert, nursing practices specialist for the Minnesota Nurses Association, said inadequate staffing could have contributed to the increase.

“Basically how you prevent (pressure ulcers) is totally by nursing care,” Diemert said. “It’s turning (the patient) and skin care and things that nurses do that certainly can be affected by not having enough staff, or the right kind of staff.”

The nurses association gets complaints from members about inadequate staffing “all the time,” Diemert said.

But Rydrych said every adverse event is analyzed, “and we hardly ever get staffing listed as a root cause or contributing factor.” Rydrych and Peterson said the increasing complexity of cases and the increased use of medical devices such as cervical collars and oxygen tubing might be a factor in producing more pressure ulcers.

Lyon attributed the absence of pressure ulcers in Essentia patients to a team of nurses led by Sandee Carlson specifically assigned to that task. “Our zero rate this year is a result of what they have done,” he said.

On the other hand, Lyon noted that Saint Marys in Rochester, the largest hospital in the state, recorded only one fall resulting in a serious disability last year. He said he’s anxious to learn more about that hospital’s strategies.

This was the eighth year the health department has released an adverse events report. Although 26 other states now have a reporting system, Minnesota is still “the only state that releases an annual report identifying hospitals by name with the number of events that happened in each hospital,” Rydrych said. “So that’s a level of transparency that does not exist in any other state right now.”

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