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Two area hospitals make medical errors report

Two lakes area hospitals made the list of 60 hospitals and two surgical centers in Minnesota that reported adverse health events last year.

The 305 adverse health events reported in 2010 included 10 deaths and 97 serious injuries, including falls, pressure ulcers and retained foreign objects during surgery.

This was a slight increase from 2009 when 301 events were reported, according to the Minnesota Department of Health.

Hospitals reporting adverse health events from Oct. 7, 2009, to Oct. 6, 2010, included Essentia Health's St. Joseph's Medical Center in Brainerd and Cuyuna Regional Medical Center in Crosby.

St. Joseph's Medical Center reported the facility had two adverse health events, including a surgery/invasive procedure on the wrong body part and the retention of a foreign object in a patient after a surgery/invasive or other procedure. Neither of these events resulted in death or serious disability.

Jani Wiebolt, president of St. Joseph's Medical Center, said one of the errors involved a piece of gauze that was left in a patient during a vaginal birth. The gauze was recovered while the mother was still at the hospital. The second event involved an orthopedic procedure where a nerve block was administered to the wrong leg. She said the mistake was noticed immediately and the nerve block was then administered to the other leg and the procedure was performed. There was no lasting harm to either of these patients, she said.

"We're sorry they occurred. One error is one too many and any error is unacceptable," Wiebolt said. "Our goal is creating a safe environment for our patients."

Barb Anderson, chief quality officer for Essentia Health, said the hospital makes great efforts to identify and report situations like these.

"Events like these are an opportunity for us to make

improvements and make even safer care down the road," Anderson said.

Anderson said the hospital last year became involved in a patient safety initiative specifically designed around obstetrics.

St. Joseph's had 49,588 surgeries/invasive procedures performed at the hospital last year. The facility has 162 beds and logged 27,102 patient days last year.

Cuyuna Regional Medical Center reported one adverse health event where a patient fell while being cared for in the facility, which resulted in serious disability. A serious disability in this case involves a fall that resulted in a fracture that required surgical repair.

"It's unfortunate that an event like this occurs, you never want this to happen," said Theresa Sullivan, chief operating officer at Cuyuna. "We take them seriously."

Sullivan said Cuyuna has worked hard on safety, implementing several safety initiatives. In 2009 the hospital received a safe from falls recognition, a statewide initiative to prevent patients from falling during their hospital stay. The hospital has a fall prevention team that tries to identify trends and strengthen the system.

During the past six months the hospital has joined the Institute for Clinical Systems Improvement, a non-profit organization that attempts to transform health care systems into delivering patient-centered care. As a provisional member, Cuyuna had to select an area of focus and the facility decided to focus on fall prevention, an initiative that will involve the entire campus, including the long-term care facility. Last year the hospital purchased software systems that is placed on a bed or a wheelchair for patients who are at risk for falling, alerting staff if they were to attempt to get up.

"We've done a lot of things," said Sullivan. "I think the key is to balance a patient's choice and input in their care while at the same time providing for their safety."

In 2010 Cuyuna Regional Medical Center had 14,526 surgeries/invasive procedures performed with 42 beds and 10,171 patient days.

Statewide there were 80 falls associated with serious injury or death that were reported, up from 76 in the previous year but down from a high of 95 falls two years ago. The number of serious bedsores remained nearly the same, a decrease from 122 to 118. The number of events related to surgery or invasive procedures remained unchanged at 83, according to the Department of Health.

"While these events are still exceedingly rare, we must never lose sight of the fact that each adverse event has an impact on a patient and their family, and that most are preventable," Diane Rydrych, assistant director for the Minnesota Department of Health Health Policy Division, said in a news release. "Because of the multiple challenges facing hospitals today, we're concerned that many health care leaders may not be fully engaged in making changes that will prevent harm to patients. That's why we are stepping up our call to action to health care leaders to strengthen their commitment to make patient safety their highest priority."

JODIE TWEED may be reached at or 855-5858.