Wrong surgery cases hit a high
An annual report shows Minnesota hospitals, while disclosing more, still struggle with preventable mistakes.
At Regions Hospital in St. Paul, Dr. James Williams, a colon and rectal surgeon, marked the incision points for Darren Lien’s abdominal surgery with a marker as part of a program to prevent errors. Photo: Richard Tsong-Taatarii, Star Tribune
Minnesota hospitals reported 26 incidents last year in which doctors performed the wrong procedures on patients — including 10 cases involving the wrong replacement joints, breast implants or cataract lenses.The figure is the highest in eight years of self-reporting by Minnesota hospitals. Officials cited many reasons for the mistakes — from doctors filling out incorrect orders to sloppy inventories that make it easy to grab the wrong joint implants for orthopedic procedures.
“There have been cases with knee implants where they’ll bring a cart into the OR that has both right and left knee implants on it,” said Diane Rydrych, who oversees the annual report for the Minnesota Department of Health. “If you’re doing a right knee, you should probably only have a cart that has right knee implants on it.”
The increase in wrong procedures stood out in an otherwise mixed report, released Thursday by the state Health Department and the Minnesota Hospital Association. The number of adverse events — often called “never events” because they are deemed preventable — climbed to a record 316 in Minnesota’s hospitals and surgery centers in 2011, up from 305 in 2010. On the other hand, the number of errors causing disabilities or deaths declined from a high of 116 in 2008 to 89 last year.
Five patient deaths were reported — three from falls, one from a medication error and one from a fatal air embolism.
The state report tracks 28 types of adverse events in all, including severe burns and surgical objects left behind during surgery.
Minnesota remains unique nationally for tracking these errors and publicizing which hospitals reported them. Few large hospitals go a year without reporting at least one.
‘Looking harder’ for mistakes
The Mayo Clinic‘s Methodist Hospital in Rochester reported 12 incidents, including four wrong procedures out of 145,589 performed last year. The University of Minnesota Medical Center, Fairview, reported 35 events, including two wrong procedures out of 164,191.
Hospital officials have warned since the first annual report in 2005 that year-to-year changes in these rare events don’t necessarily reflect improving or declining safety. More hospitals are reporting errors now, including surgical errors that take place in radiology, obstetrics and other departments — not just in operating rooms.
“I can guarantee we look harder for these kind of events,” said Dr. Craig Svendsen, chief medical quality officer for the HealthEast Care System, which includes St. Joseph’s, St. John’s and Woodwinds hospitals. HealthEast reported 10 adverse events last year.
Hospital officials say it can be frustrating, from one year to the next, to see a drop in one kind of adverse event and an increase in another. Surgeries on the wrong body part fell from 31 in 2010 to 24 in 2011, for example, while the tally of wrong procedure cases jumped from 16 to 26.
There were also 37 reported cases of objects left behind during various procedures. This year, however, none of them involved women in childbirth, thanks to new systems for counting sponges in obstetrics. “We’ve had some real success in labor and delivery, and I think that’s a great example of how we’ve been able to put in place a new community-wide standard,” Rydrych said. “Prior to this work, counting sponges and doing visual inspections of the area in labor and delivery were not the norm. Now they are.”
Fragments left behind
The new challenge, she said, involves fragments of surgical tools breaking off in patients. Sometimes, sponges are left in patients temporarily to aid in their recoveries, but nobody remembers to take them out.
None of the wrong-procedure cases resulted in severe disability or death. Many of the errors were discovered after surgery when patients reported discomfort, Rydrych said. Often the patients who received the wrong implants had surgery to fix the mistakes.
Most hospitals have adopted safeguards, such as “timeouts” before surgeries, to make sure surgeons perform the proper procedures and have the right equipment. The state report noted concerns, though, that some hospitals still don’t use timeouts or pauses while others don’t take them seriously enough.
“It’s not [supposed to be] just a superfluous kind of quick thing, but really something with content and purposefulness,” said Dr. Mark Werner, Fairview’s chief clinical integration officer.
The Minnesota Alliance for Patient Safety, a coalition of hospital and health care leaders, also is examining how to prevent errors that occur when inaccurate information is passed between the surgeon and the hospital. Electronic record systems can be part of the problem if they require separate entries for ordering surgeries and scheduling them.
Werner said public reporting has increased patient safety and eliminated the easy-to-fix mistakes.
Fairview reported five wrong procedures at its University and Southdale hospitals last year. Werner said they included complex cases in which the pre-op imaging scans or reports turned out to be misleading. Eliminating errors in these situations will be tougher than preventing errors from inaccurate paperwork.
“We’re getting down,” he said, “to the hard nuts to crack.”
Jeremy Olson • 612-673-7744
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