Report: Adverse health events up at area facilities, statewide | Local News

MANKATO — The number of adverse health events, considered “often preventable,” rose overall at south-central Minnesota health care providers during the latest reporting year.

The Minnesota Department of Health’s annual report on the incidents, released last week, included six area providers and 21 total incidents compared to three providers and 12 incidents during the prior year. The more recent incidents ranged from ulcers to falls to a sexual assault.

Most of the adverse events, 15, resulted in no injuries, while six caused serious injuries and none were fatal.

Mayo Clinic Health System in Mankato had 16 of the 21 incidents between Oct. 7, 2022-Oct. 6, 2023. Twelve of its incidents were ulcers causing no serious injuries. The facility also had two falls causing serious injuries, a serious injury from retention of a foreign object in a patient after a surgery or other procedure, and a surgery/other invasive procedure on the wrong body part causing no serious injury.

The 16 total incidents at Mayo in Mankato was an uptick from seven during the previous reporting year, although serious injuries declined from five to three. A statement from the health system referenced rising patient volumes at the facility and noted a process is in place to respond to events.

“Quality and patient safety are engrained in Mayo Clinic’s core values,” the statement read. “With patient volumes steadily rising at our Mayo Clinic Health System hospitals in Minnesota, we are incredibly grateful to our teams for providing exceptional, high-quality care patients expect and deserve, and we commend them for their vigilance in speaking up to report safety concerns. Our teams review and learn from each event and develop strategies to improve care and drive systemic improvement.”

Mayo Clinic Health System facilities in Waseca and St. James had one adverse event each in the report. Waseca’s incident was a “misuse or malfunction of device” causing a serious injury, after having zero incidents reported during the prior year. St. James’ was a fall causing a serious injury — it also had one incident during the previous reporting year.

Mankato Surgery Center had one incident reported, matching last year’s total. The most recent adverse event was an “irretrievable loss of an irreplaceable biological specimen” resulting in no serious injury.

The other events at south-central facilities were one each at River’s Edge Hospital & Clinic in St. Peter and Allina Health’s New Ulm Medical Center. River’s Edge had a fall causing a serious injury, while New Ulm had a sexual assault of a patient resulting in no serious injury, according to the report.

South-central Minnesota’s rise in total incidents and uptick in number of providers with incidents aligned with the statewide trend. Minnesota had 610 total adverse events in the latest reporting year, up from 572.

It was Minnesota’s fourth straight year with increases in adverse health events, according to a release from the health department. Severe injuries rose from 178 to 222 year-over-year, although deaths from incidents declined from 21 to 16.

Despite the increases, adverse health events are relatively rare compared to patient volumes, stated Minnesota Commissioner of Health Dr. Brooke Cunningham. Still, she said the number and severity of incidents is troubling.

“We remain committed to conducting these types of analyses and advocating for changes in how care is delivered to improve outcomes and ensure patient safety for all Minnesotans,” she stated.

Pressure ulcers and falls were by far the most common events. Falls in particular fueled the increase in total events, rising by 21%.

Dr. Rahul Koranne, president and CEO of the Minnesota Hospital Association, pointed to financial and workforce deficits at hospitals and health systems as contributors to the increase in adverse health events.

“But the latest reports of these events show providers are even more committed to the surest route to improvement: tracking what goes wrong, learning why it happened and striving to do better,” he stated in the release.

Follow Brian Arola @BrianArola

Follow Brian Arola @BrianArola


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