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.
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.
Attorney Fred Pritzker 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 Fred, 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)