By John Tingle
Patient safety is not only a UK problem, it remains an issue of global concern for all countries across the globe. WHO puts the issue in a global context:
“According to a new study, medical errors are the third leading cause of death in the United States. In the United Kingdom, recent estimations show that on average, one incident of patient harm is reported every 35 seconds.” (p1.)
Whilst the health care environments may differ across the world, the great leveller or common feature is that we are all dealing with human beings. By looking at what other countries do and report about patient safety we can avoid the costly mistake of trying to reinvent the wheel when information is already available about important trends.
The Minnesota Department of Health (MDH) have recently published their 14th Annual Public Report on Adverse Health Events in Minnesota. The report contains a lot of detailed patient safety information, analysis and trends which will be of use to health carers and patient safety policy developers everywhere.
In 2003 Minnesota became the first state in the USA to establish a mandatory adverse health care events reporting system by law that tracks events such wrong-site surgery etc. The legislation covers Minnesota hospitals, free standing outpatient surgical centres and regional treatment centres. These facilities are required by law to disclose when any of 29 serious reportable events occur.
The report, shows that between October 7, 2016, and October 6, 2017, 341 adverse health events were reported to the MDH.There was an increase in fall related deaths,wrong site surgical /invasive procedure events and a decrease in pressure ulcer reports. There were 12 deaths and 103 serious injuries reported. The report states that over the life of the reporting system in Minnesota, falls, medication errors and product, device malfunction have been the most common cause of serious patient injury or death.
The report states that as in previous years, falls and pressure ulcers were the most commonly reported types of events, accounting for 59 per cent of all reported events (202 events) followed by surgical, invasive procedures at 24 per cent (83 events). There were 36 cases of wrong site surgeries, invasive procedures reported and 27 cases of retained foreign objects (RFO) after surgeries or invasive procedures. The majority of these (59 per cent) occurred in an operating theatre, either as an in or out patient.
Nearly half, 48 per cent of the RFO’s were described as ‘soft goods’, such as sponges and other soft pads. Pressure ulcers have been the most commonly reported adverse health event since the reporting system first began in 2003.Pressure ulcers often represent roughly a third of reported events. The top pressure ulcer sites were in the area of the coccyx, sacrum (40 per cent), face, ear (12 per cent) and buttocks (6 per cent).
In terms of clinical unit location where these events occurred, the majority occurred in the ICU (Intensive Care Unit) (53 per cent), and 29 per cent occurred in adult medical surgical units.
The report states that there were 77 reported falls that resulted in serious injury to a patient as well as 5 fatal falls. This is the second year of an increase in the number of falls reported.
The report provides an excellent real-time view of some major patient safety issues in a very clear and concise way and has a global value in terms of patient safety policy development and practice.