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Hospitals stumble in preventing harmful “never events”

NEWS IN BRIEF — Posted Feb. 11, 2013

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The severity of serious reportable events in Minnesota hospitals rose in 2012, a step back from the progress seen in 2011.

Hospitals reported 314 so-called never events such as serious pressure ulcers, falls and wrong-site surgeries, down from 316 reported in 2011. But the number of patient disabilities attributed to the mistakes rose from 84 to 89, while related patient deaths jumped from five in 2011 to 14 in 2012, said the Minnesota Dept. of Health’s annual report on adverse events (link).

Under a 2005 state law, hospitals are required to report any of 28 serious reportable events. In 2008, the first year that hospital reports were made public, never events killed or disabled 116 patients. Those figures have seesawed in subsequent years, with no clear improvement trend.

In 2012, 41% of never events involved pressure ulcers, 26% were surgical mistakes such as retained objects and wrong-patient procedures, and 25% involved falls. The remainder were events such as serious drug errors.

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