mayo never

Dec. 4--Mayo Clinic has again reported deaths related to medical "never events," events health experts believe should "never" occur in the health-care environment.

Each year, up to 98,000 Americans die from medical errors, according to the 1999 Institute of Medicine report called "To Err is Human: Building a Safer Health System."

In 2003, the Minnesota Adverse Health Care Events Act was passed at the urging of hospitals. It requires reporting of never events once each year. The state's goal is to alert hospitals whenever errors are recognized as potentially repeatable.

Increasing attention nationwide has led to increased public disclosure. St. Cloud Hospital, for example, reports blood-infection rates and prices for its most-common treatments.

Mayo Clinic began in May of 2007 to share medical-error summaries with its 31,000-plus Rochester employees four times yearly, rather than the annually as required.

In the 2008 fourth quarter employee newsletter, Mayo reported that during the fourth-quarter reporting period:

--Two patients died after preventable falls. Both experienced brain bleeding before death.

--Two patients were disabled by falls. One received a "two-part" shoulder fracture. The other "sustained a ruptured eye globe." Both required surgery.

"The Mayo Fall Prevention Subcommittee is actively involved in identifying interventions that will minimize harm from falls," the clinic noted.

--Two patients had serious disability associated with medication errors. One still had a "neurological deficit" at discharge.

New protocols and better chemotherapy prescribing supervision were begun. The other patient got inadequate anticoagulation, yielding paralysis on one side of the body.

--Three patients had items still in them after surgery. One had an object in the eye after retinal reattachment surgery.

"The object eventually migrated to the eyelid and was removed," Mayo reported in the employee newsletter. A sponge was retained in another patient, and a guide wire came out of a central venous catheter and had to be removed from a third.

Staff will get hands-on training about the catheters, the clinic reported. Post-surgery item counts are also being emphasized.

--Five patients got pressure ulcers during prolonged hospitalizations. A prevention team was set up.

To put the errors in context, Mayo reported in March that it treated 520,000 patients in 2007.

For more information, visit Postbulletin.com/weblinks.

St. Cloud Hospital, click on "Quality, Safety & Pricing": http://www.centracare.com/hospitals/sch/index.html

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