ST. PAUL, Minn. - While the number of what the Minnesota Department of Health (MDH) calls "adverse health events" stayed flat over the past year, deaths and serious injuries are actually up, according to a report released Thursday.
The report indicates there were 14 deaths in 2012 compared to five in 2011 and 89 serious injuries compared to 84 in 2011. While most of this increase was due to a higher number of serious falls, deaths related to suicides and elopements also increased slightly.
"This year's report shows that as a state we really need to redouble our efforts to reduce falls in hospitals," said Minnesota Commissioner of Health Dr. Ed Ehlinger. "While falls in health care settings can be very difficult to prevent, we also need to look at all opportunities to prevent injury when falls do occur, by focusing interventions on each patient's specific risk factors."
Nearly 90 percent of the cases of harm or death were a result of falls. Over the life of the reporting system falls, medication errors, and suicide have been the most common causes of serious patient harm or death.
During the same period, the number of serious bedsores, retained foreign objects and medication errors decreased. The adverse health events reporting system tracks 28 types of serious events, such as wrong-site surgeries, severe bedsores, falls, or serious medication errors, which should rarely or never happen.
This is the ninth year that MDH has produced the report, which also found hospitals and surgical centers improved in several key areas during 2012;
- The number of total pressure ulcers (bedsores) declined by eight percent. This is the first decline of this magnitude in the nine years of reporting. This year's total of 130 is down from a high of 141 last year.
- Retained foreign objects declined by 16 percent. This is the first decline in this category in five years.
- Medication errors dropped by 75 percent from the previous year and were at the lowest level in all nine years of reporting.
According to the report, in 2012 hospitals did a better job of identifying patients at risk for falling and checking on them at frequent intervals, but there is still work to be done in terms of creating tailored plans for each patient and sharing a patient's risk for falling with every member of the care team. Patients also need to be aware of the dangers of moving around without assistance.
In nearly 60 percent of falls, a care team member had completed a rounding visit with the patient within 30 minutes prior to the fall, to check on pain, position and toileting needs, but the patient then got up on their own to use the toilet.
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