Twenty patients died in Minnesota hospitals during a 15-month period because of medical errors or oversights including falls, faulty medical equipment and administering the wrong medication, the state Health Department said in a new report.
The report, released Wednesday, documented 99 serious errors between July 1, 2003 and Oct. 6, 2004. Minnesota is the first state to report its mistakes under standards developed by the National Quality Forum, a Washington-based nonprofit. New Jersey and Connecticut also adopted the standards, which are being considered elsewhere.
Minnesota’s most common problem — not resulting in death or disability — was doctors forgetting foreign objects such as surgical sponges inside patients at the end of operations. That happened 31 times.
St. Luke’s Hospital in Duluth reported the most deaths due to medical errors, with four. The causes were a fall, a medication error, a malfunctioning medical device and a burn.
Thousands die annually
Three patients died after medical errors in Mayo Clinic facilities in Rochester and Mankato, including two who received incorrect medications and one apparently healthy patient who died after an operation.
In a 1999 report, the Institute of Medicine estimated that 44,000 to 98,000 Americans die annually because of medical mistakes. Since then, 22 states have adopted laws requiring hospitals to report serious mistakes, according to the National Academy for State Health Policy.
The National Quality Forum, which sets voluntary hospital standards, developed a list of 27 mistakes such as amputating the wrong limb or sending a baby home with the wrong family. They’ve been dubbed “never” mistakes because they’re so serious they’re never supposed to happen.
It is those 27 mistakes that Minnesota hospitals reported Wednesday.
Health Commissioner Dianne Mandernach said collecting and publishing data on medical errors will improve safety for hospital patients in the long run.
“The true value of our new reporting system lies not in the numbers but in the underlying evaluation of the causes of the errors and the actions that are taken to prevent them from ever occurring in the future,” Mandernach said at a news conference.