Fairview reported 24 adverse health care events to the Minnesota Department of Health during the law's fourth reporting cycle, Oct. 7, 2006 to Oct. 6, 2007. The report appears annually as part of a state law to encourage shared learning about, and prevention of, adverse health events.

"We sincerely regret any harm done to a patient; we are accountable for the care we provide," says Alison Page, M.S., M.H.A., Fairview chief safety officer. "We strive to lead in transparency and sharing patient safety learning across the community and beyond. Fairview participated in the development and implementation of Minnesota's adverse health event law."

Fairview will continue to be a leader in reporting and sharing patient safety learning within the system and across the community, state and nation. Following are the main categories of Fairview's most recent adverse health events:

1) Wrong body part or site procedures and wrong procedures (9 events)—These events include such procedural errors as radiation therapy or anesthesia delivered to the wrong site. They also included surgery or biopsy on the wrong body part or organ.  

In 2008, staff will continue work to prevent wrong-site procedures and wrong procedures by participating in the Minnesota Hospital Association's SAFE SITE initiative. Launched Dec. 4, the initiative builds on efforts such as the "hard stop," during which clinicians do not move a patient into the OR if the surgeon has not signed the surgery site or staff has not completed and reconciled the informed consent and verification process. Future efforts will focus on reliably performing the final pause before a procedure to ensure the right patient is getting the right procedure on the right site.

2. Serious pressure ulcers acquired after admission (8 cases)—This breakdown of the skin typically occurs in very sick, unstable patients, sometimes in a span of only a few hours. Pressure ulcers can result from pressure on the skin over a bone, abrasion from tubes or pumps, incontinence or poor absorption of nutrition, among other factors. They can occur in patients with end-stage disease who do not tolerate movement or turning or in those who refuse turning.

Fairview has introduced multiple prevention strategies, including standardized risk evaluations and skin assessments, posted skin safety measures, pressure reduction mattresses and other equipment, trained skin safety coaches, implemented incontinence protocols, turning reminder clocks, improved documentation tools and resources manuals. In addition to emphasizing pressure ulcer prevention protocol and revising the policy, clinical leaders will continue to focus on staff and patient/family education and awareness, as well as documenting thoroughly each event and intervening at the first sign of a pressure ulcer.

"We're taking all the cases from this year and performing a common cause analysis," says Diane Nalezny, quality and patient safety, University of Minnesota Medical Center, Fairview. "We'll look for themes in the big picture that we might be missing." Results of the common cause analysis will determine pressure ulcer prevention initiatives in 2008.

Fairview's reported adverse health events included:

Fairview Lakes Medical Center (Wyoming)

• Surgery/procedure performed on a patient that is not consistent with documented informed consent; no harm caused to patient.

Fairview Northland Medical Center (Princeton) 

• Retention of foreign object in patient after surgery or other procedure; no harm caused to patient.

Fairview Red Wing Hospital

• No reported events.

Fairview Ridges Hospital (Burnsville)

• Surgery or procedure on wrong body part or site; no harm caused to patient.
• Surgery or procedure on wrong body part or site; no harm caused to patient.
• Serious disability associated with a medication error; treatment required.

Fairview Southdale Hospital (Edina)

• Wrong procedure performed on a patient; no harm caused to patient.  
• Wrong procedure performed on a patient; monitoring required to determine that no interventions will be needed.
• Wrong procedure performed on a patient; monitoring required to determine that no interventions will be needed.
• Wrong procedure performed on a patient; treatment required.
• Retention of foreign object in patient after surgery or other procedure; treatment required.
• Serious disability associated with a medication error; treatment required.
• Death associated with a fall.
• Serious pressure ulcer acquired after admission; treatment required.
• Serious pressure ulcer acquired after admission; treatment required.

University of Minnesota Medical Center, Fairview (Minneapolis)

• Surgery or procedure performed on the wrong body part or site; no harm caused to patient.
• Surgery or procedure performed on the wrong body part or site; treatment required.
• Retention of foreign object in patient after surgery or other procedure; no harm caused to patient.
• Serious pressure ulcer acquired after admission; treatment required.
• Serious pressure ulcer acquired after admission; treatment required.
• Serious pressure ulcer acquired after admission; treatment required.
• Serious pressure ulcer acquired after admission; treatment required.
• Serious pressure ulcer acquired after admission; treatment required.
• Serious pressure ulcer acquired after admission; treatment required.
• Innappropriate sexual contact between adolescent patients.

Fairview-University Medical Center-Mesabi (Hibbing)

• No events reported.