Email: That’s the Wrong Knee

That’s the Wrong Knee
	Imagine that you go to the hospital for a knee implant. You enter surgery and wake up to find that your procedure went smoothly. You feel great—only the surgeon operated on the wrong knee!

This is an example of a “never event”—an adverse yet preventable incident that occurs in the hospital. This includes falls, pressure ulcers, and errors with prescription drugs, among others. The frequency of these events indicates the safety and quality of hospital care.

In 2003, Minnesota became the first state to require adverse events to be reported to the Department of Health. The 8th Annual Report on Adverse Health Events in Minnesota (PDF), released this month, has some good news and some bad news about the state of patient safety in Minnesota’s hospitals.

The bad news: The total number of adverse health events went up from 305 to 316 between 2010 and 2011. This trend can be traced back largely to a 19% increase in the number of pressure ulcers and a 63% increase in the number of wrong procedures (from 16 to 26).

While the increase in pressure ulcers may be at least partially attributable to a growing emphasis on recognizing and treating these events, the increase in wrong procedures is worrying. Wrong procedures are mistakes in the type of treatment—for example, the wrong kind of knee implant. They’re usually not serious and are corrected immediately, but these mistakes should never be made in the first place.

The good news: Though the total number of never events went up in 2011, the number of events that lead to serious injury or death decreased from 107 to 89—the lowest since 2007. In particular, there were fewer serious falls. That’s a commendable reduction in harm. A decline in wrong site surgeries (in which, for example, a surgeon operates on the wrong limb) helped improve patient outcomes. An initiative to count sponges and other objects during labor and delivery resulted in no retained foreign objects left in patients.

Minnesota hospitals are doing a good job with patient safety. But to bring down the numbers of never events, they need support for stricter safety initiatives. Procedures and checklists that encourage double-checking and errorless care are imperative for the reduction of adverse events. According to the MDH report, “this means that organizational cultures need to be transformed so that safety, efficiency, and quality are continually at the forefront. Small technical changes or one-off actions will not be sufficient; complex, ongoing, sometimes uncomfortable adaptive change is needed.”

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