Reports of Serious Disability and Death by Minnesota Hospitals between October 7, 2010, and October 6, 2011
Minnesota hospitals, ambulatory surgical centers and community behavioral health hospitals must report certain serious adverse health events to the Minnesota Department of Health (MDH). In 2011, the eighth year of reporting, the total number of events reported under the law is 316, a slight increase from the 305 events reported in 2010. Of the 316 adverse health events reported, 84 resulted in serious disability and 5 resulted in death.
These serious disabilities and deaths were caused by the following, according to the adverse health events report issued by MDH:
- Surgery or invasive procedure on the wrong body part – one serious disability;
- Misuse of malfunction of a medical device – one serious disability;
- Intravascular air embolism related to medical device – one death;
- Patient disappearance – one serious disability;
- Attempted suicide by patient – one serious disability;
- Medication error – 7 serious disabilities and one death;
- Disability during low-risk pregnancy, labor or delivery – 2 serious disabilities;
- Failure to treat hyperbilirubinemia (newborn screening should prevent this condition that is associated with severe jaundice) – one serious disability;
- Pressure ulcer (bed sore) – 2 serious disability;
- Fall at Hospital or Facility – 68 serious disability and 3 deaths;
Hospitals and Other Facilities Reporting Serious Disability or Death
The following hospitals reported serious disability (SD) or death between October 7, 2010, and October 6, 2011 to the Minnesota Department of Health (2011 Adverse Health Events Report):
Abbott Northwestern Hospital, Minneapolis – 7 SD from fall;
Avera Marshall Regional Medial Center, Marshall – One SD from fall;
Bethesda Hospital, St. Paul – One SD from fall;
Buffalo Hospital – One SD from fall;
Essentia Health Sandstone – One death from a medication error and one SD from fall;
Essentia Health St. Joseph’s Medical Center, Brainerd – One SD from fall;
Essentia Health St. Mary’s Hospital, Detroit Lakes – One SD from fall;
Essentai Health St. Mary’s Medical Center, Duluth – 3 SD from fall;
Fairview Lakes Medical Center, Wyoming, MN – One SD from fall and one SD from a medication error;
Fairview Ridges Hospital, Burnsville – 2 SD from fall;
Fairview Southdale Hospital, Edina – One SD from a medication error;
Grand Itasca Clinic & Hospital, Grand Rapids – One SD from fall;
Hennepin County Medical Center, Minneapolis – 9 SD from fall;
Hutchinson Area Healthcare, Hutchinson – 2 SD from fall;
Lakewood Health Center, Baudette – One SD from fall;
Lifecare Medical Center, Roseau – One SD from fall;
Madison Hospital – One SD from fall;
Maple Grove Hospital – One SD from low risk pregnancy, labor or delivery;
Mayo Clinic Health System, Austin – One SD from medication error;
Mayo Clinic – Methodist Hospital, Rochester – 2 SD from fall and one SD from use or malfunction of a medical device implant;
Mayo Clinic – St Mary’s Hospital, Rochester – One death from fall;
Meeker Memorial Hospital, Litchfield – 2 SD from fall;
Mercy Hospital, Coon Rapids – 2 SD from fall;
New Ulm Medical Center – One SD from fall;
North Memorial Medical Center, Robbinsdale – 2 SD from fall;
Park Nicollet Methodist Hospital, Minneapolis – One SD from medication error;
Rainy Lake Medical Center, International Falls – One SD from fall;
Regina Medical Center, Hastings – One SD from fall:Ridgeview Medical Center, Waconia – One SD from fall;
Riverwood Healthcare Center, Aitkin – One SD from fall;
Saint Elizabeth’s Medical Center, Wabasha – One SD from fall;
Sanford Bemidji Medical Center, Bemidji – One SD from pressure ulcer;
Sanford Luverne Medical Center, Luverne – One SD from fall;
Sanford Worthington – One death from fall;
Sleepy Eye Medical Center – One SD from fall;
St. Cloud Hospital – 3 SD from fall;
St. Francis Regional Medical Center, Shakopee – One death from fall;
St. John’s Hospital, Maplewood – One SD from a surgery or other invasive procedure performed on the wrong body part, 2 SD from medication error, one SD from fall;
St. Joseph’s Area Health Services, Inc., Park Rapids – One SD from fall;
St. Luke’s Hospital, Duluth – 3 SD from fall;
St. Michael’s Hospital & Nursing Home, Sauk Centre – One SD from fall;
United Hospital, St. Paul – One SD from attempted suicide, one SD from pressure ulcer, and 3 SD from fall;
University of Minnesota (U of M) Medical Center – Fairview, Mpls – One death from an intravascular air embolism, one SD from a patient disappearance, one SD from medication error, one SD from failure to identify and treat excessive bilirubin in new born (hyerbilirubinemia and jaundice), and 5 SD from fall.
Attorneys Fred Pritzker and Elliot Olsen are our lead attorneys for our Minnesota medical malpractice cases. Both Fred and Elliot were again named “Minnesota Super Lawyers” by Law & Politics magazine in 2011. To contact them or another attorney at PritzkerOlsen, P.A., submit our free consultation form or call 1-888-377-8900 (toll free) or 612-338-0202.
Number of Pressure Ulcers (Bed Sores) and Wrong Procedures Increases in Minnesota Hospitals
The number of pressure ulcers (bed sores) and wrong procedures in Minnesota hospitals, ambulatory surgical centers and community behavioral health hospitals increased in 2011, according to the eight annual adverse health events report released today by the Minnesota Department of Health. The report summarizes the number and types of adverse health events that occurred between October 7, 2010, and October 6, 2011, in the 200 facilities covered by the adverse health events reporting law.
The number of pressure ulcers rose to 141, an increase of 19 percent, while reports of wrong procedures increased by 63 percent, to 26. Due primarily to these two categories, the total number of adverse health events reported under Minnesota law rose from 305 in 2010 to 316 in 2011.
Pressure Ulcers (Bed Sores)
The number of reported pressure ulcers (bed sores) increased in 2011, rising from 118 to 141. This figure does not represent the total number of bed sore injuries suffered by patients in Minnesota because nursing homes are not required to report bed sore cases under the adverse health events reporting law.
The majority of reported pressure ulcers were found on the coccyx or buttocks (39 percent), on the head, neck or face (23 percent), or on the sacrum (13 percent). Cases of pressure ulcers on the neck and face are caused by device use, most commonly respiratory equipment. Other devices, such as immobilizers, also caused pressure ulcers.
According to the Minnesota Department of Health report, the root cause of the pressure ulcers from medical device use is inadequate training:
Even when devices contribute to the development of an ulcer, the root cause of the pressure ulcer is often more closely related to a lack of understanding of risk for skin breakdown with device usage and a breakdown in the implementation of appropriate steps for prevention of the formation or progression of such an ulcer. In some cases, nursing staff may not be familiar enough with the device to know how to inspect under or around it, or policies for when and how such inspections are done may be unclear. In other cases, information related to removal or proper fit of devices may not be effectively communicated from the ordering physician to the care team.
Wrong Procedure
Minnesota hospitals and ambulatory surgical centers reported 26 cases of wrong procedures. Ten of the wrong procedure events reported by Minnesota hospitals in 2011 were related to incorrect implants being placed:
- 5 during cataract surgeries in which the wrong power lens was placed
- 2 during breast implants in which the wrong type of implants were placed
- 2 during knee replacement surgeries
- One during an ankle surgery.
Attorneys Fred Pritzker and Elliot Olsen of our office has a niche practice handling medical malpractice and product liability cases involving implants and other medical devices. He can be reached at 1-888-377-8900 (toll free) or locally at 612-338-0202. After hours, you can leave a message for Elliot, and he will return your call as soon as possible.
When a wrong procedure or other reportable adverse event occurs, facilities are required by Minnesota’s adverse health events reporting law to conduct a root cause analysis. This is an important step in determining exactly what happened and why, but patients who injured in this way can contact our attorneys for a free consultation regarding an independent investigation and lawsuit against the hospital or other facility.
According to the Minnesota Department of Health report, “the root causes of wrong procedure events are often related to breakdowns in the verification processes that lead up to the procedure.These processes can begin weeks before the event, when the procedure is initially ordered or scheduled by a physician’s office, and continue up until the moment the procedure begins or even beyond.Often, these breakdowns occur when source documents do not include correct information at the time a procedure is scheduled or performed, or when that information is not included in the verification process.”
Root causes for the wrong procedures reported for 2011 included:
- Right and left knee implant components being placed on the same cart, with similar labeling;
- Consent forms that did not include the specific implant to be used;
- Scheduling forms that were modified when the surgical plan changed and not re-verification after the modification was made; and
- Electronic health records systems that include separate scheduling and ordering modules for different clinical areas and which do not always interface in real time.
Hospitals and Other Facilities Reporting Pressure Ulcers and Wrong Surgical/Invasive Procedures
The Minnesota hospitals and other facilities reporting pressure ulcers (PU) and/or wrong procedures (WP) are listed below (pressure ulcers include stage 3, 4 or unstageable pressure ulcers (with or without death or serious disability)):
Abbott Northwestern Hospital, Minneapolis – PU (4) and WP (1)
Bethesda Hospital, St. Paul – PU (6)
Centra Care Health System, Melrose – PU (1)
Children’s Hospitals & Clinics of Minnesota, Minneapolis – PU (4) and WP (1)
Children’s Hospitals & Clinics of Minnesota, St. Paul – PU (1)
Essentia Health, Duluth – WP (2)
Essentia Health St. Josephs Medical Center, Brainerd – PU (1) and WP (1)
Fairview Lakes Medical Center, Wyoming, MN – PU (1) and WP (1)
Fairview Southdale, Edina – PU (4) and WP (3)
Gillette Children’s Specialty Healthcare, St. Paul – PU (1)
Hennepin County Medical Center, Minneapolis – PU (22)
ILBNC Special Procedures Surgery Center, Plymouth – WP (1)
Maple Grove Hospital, Maple Grove – PU (1)
Mayo Clinic – Methodist Hospital, Rochester – PU (3) and WP (4)
Mayo Clinic – St. Mary’s Hospital, Rochester – PU (38) and WP (2)
Mercy Hospital, Coon Rapids – PU (2)
North Memorial Medical Center, Robbinsdale – UP (5) and WP (1)
Park Nicollet Methodist Hospital, St. Louis Park – UP (5) and WP (3)
Regions Hospital, St. Paul – PU (5) and WP (1)
Riverview Health, Crookston – PU (1) and WP (1)
Sanford Bemidji Medical Center, Bemidji – PU (1)
South Central Surgical Center, Fairmont – WP (1)
St. Cloud Hospital, St. Cloud – PU (1) and WP (1)
St. Fransis Regional Medical Center, Shakopee – PU (1)
St. John’s Hospital, Maplewood – PU (2)
St. Joseph’s Hospital, St. Paul – PU (1)
St. Luke’s Hospital, Duluth – PU (3)
United Hospital, St. Paul – PU (5)
United Hospital, Fridley – PU (3)
University of Minnesota Medical Center – Fairview, Minneapolis – PU (17) and WP (2)
Winona Health Services, Winona – PU (1)
Woodwinds Health Campus, Woodbury – PU (1)
