Hospital 'adverse events' rose during pandemic in Minnesota

COVID-19 put Minnesota hospitals under extreme pressure at peak points over the past two years, and the latest adverse event data show some of the human cost.

Fatal or disabling falls of hospitalized patients increased during the pandemic, and severe bedsores appeared in unexpected places as COVID patients were rotated from their backs to their bellies for days to support their failing lungs.

Collectively, hospitals disclosed a record 508 reportable adverse events in the 12 months ending in October 2021, according to a report Wednesday by the Minnesota Department of Health. That total, exceeding the 382 disclosed the prior year, caused 207 serious injuries or corrective surgeries and 14 deaths.

While the pandemic can get the brunt of the blame, hospitals don't get a "free pass" for errors that are ultimately preventable with the right staff and safety policies in place, said Jennifer Schoenecker, associate vice president for quality and safety for the Minnesota Hospital Association. Trends were improving before the pandemic.

Hospitals must "learn from the past couple of years and then recover," Schoenecker said. "We know that the work we're doing works. We are improving quality and safety, and these last two years have certainly challenged the progress we made. We need to get back now to the point where we're going to start seeing that decline again."

The 86 fatal or disabling falls reported Wednesday went beyond the 61 recorded the prior year and the annual average of 75 since 2010. Falls increased from seven to 15 just at Mayo Clinic hospitals in southeast Minnesota, where COVID-related gowning and personal protection requirements made it harder for staff to get to patients in time, said Dr. Kannan Ramar, Mayo's chief safety officer.

Mayo has an arm's-reach policy requiring a nurse or staff member to be there any time a patient at risk of falling gets up, but it's dependent on adequate staffing, Ramar added. "The workforce shortage and the turnover, to be honest, that doesn't help matters," he said.

Even COVID-related restrictions on visitors played a role, Schoenecker said, because friends and relatives can bring patients meals, phones and provide an extra set of eyes before falls occur.

The 217 severe bedsores in the latest report marked an increase from 169 the prior year as well — adding wounds and sepsis infection risks for patients who were already ill.

The average length of stay in critical care doubled to nearly 5.5 days last year, which increased the risks for largely immobile patients, according to the state report. Poorer vascular health especially increased the risks for COVID patients, who were rubbing against mattresses and tubes when they were placed face down in prone positions.

Bedsores normally appear on elbows, heels and other bony parts of the back of the body, Ramar said. "We started noticing pressure injuries in areas around the chin, the forehead area, around the breathing tube, around the mouth area — things that we hadn't seen before," he said.

Mayo and other hospitals saw their reportable bedsore numbers decline later in the pandemic as they became more adept at managing the new risks.

Minnesota was the first state in 2005 to publicly report adverse events by hospital. The pandemic prompted the state to pause its usual annual reporting of 29 types of adverse events, and the state belatedly released the data for reports in 2020 and 2021. There were oddities as well in the report issued last year, which covered the 12 months ending in October 2020 and included Minnesota's first COVID wave and the start of the second.

CentraCare's Rice Memorial Hospital in Willmar provided the state's first-ever report of someone being injured when a metallic object was introduced in the hyper-magnetic environment of an MRI imaging bay. Spokeswoman Karna Fronden declined to elaborate, but said "for all adverse health events, we do perform a root-cause analysis to see if anything could have been done differently."

Results of such analyses are shared statewide to prevent similar errors, part of the unique collaboration by which Minnesota hospitals endure individual humiliation as a trade-off for broader safety improvements.

Pandemic pressures showed in other ways, including the discharges of children or adults lacking decisionmaking capacity on their own, or releasing them to the wrong people. Five such events were reported in the last two years, compared with two in the prior 15 years.

One case, at M Health Fairview's Range Medical Center in Hibbing, occurred at a pandemic peak when a young adult was moved from an overcrowded emergency room to urgent care. The new caregivers discharged the patient, unaware of the requirement that legal guardians be there for pickup.

The young adult got home safely. But the health system changed its electronic medical records to make sure all caregivers are alerted to discharge instructions, said Dr. Abe Jacob, chief quality officer for the health system.

"Adverse health events are rare," he said, "but any event in our health care system is too many."

Rushed hospitals also reported a record 36 incidents in which irretrievable biological specimens were lost — preventing or delaying patients from being diagnosed and treated. In response, many hospitals added tamper-proof containers and secure delivery systems because many specimens were lost in transit, said Rachel Jokela, director of the state's adverse event reporting system.

"That falls in line with some of what we saw related to health care in the pandemic," she said. "There were so many moving pieces that sometimes things got lost in the shuffle, unfortunately."

Surgical adverse events increased statewide from 73 to 90 in the most recent year, but that was somewhat expected. Surgical volumes declined in 2020, when the state canceled nonemergency procedures for two months during the beginning of the pandemic. The number of scheduled operations rebounded in 2021.

The total included 36 occasions in which needles, sponges, catheters and other objects were accidentally left inside patients. The state in 2020 changed its reporting of these incidents to make sure that any resulting in a corrective procedure was classified as a serious injury.

Only eight injuries and one death from such surgical errors had been reported before 2020, but 53 injuries have been disclosed in the last three reports.

Jokela said she was proud that hospitals maintained reporting and safety procedures through the pandemic, preventing other surgical errors with no direct COVID connection.

"It's not like we saw surgical events go through the roof," she said. "Those event numbers were very in line with where they were pre-pandemic."