When it comes to medical mistakes, understanding how and why they happen is critical to preventing them. Each year, the Minnesota Department of Health releases a report addressing medical errors across the state. The incidence of these errors has trended slightly upward since 2014. In 2022, that trend continued, with 508 total errors (up from 382 in 2020), 207 serious injuries, and 14 events that lead to death.
Most prevalent types of mistakes
As in past years, bed sores (also called pressure ulcers) were the leading type of adverse event in 2021, accounting for nearly 60 percent of all cases. Bedsores can cause serious harm in vulnerable patients. If not promptly caught and treated, they can lead to infection, sepsis and death.
Typically, at-risk patients are immobile and suffering from poor circulation. Friction from bedding – and pressure on the skin from remaining in the same position for an extended period of time – can result in painful lesions. Medical devices such as feeding tubes and cervical collars can also contribute.
Bedsores shouldn’t happen with the right care. Prevention involves regularly repositioning patients and diligently monitoring their skin for irritation (especially the tailbone, head and neck areas).
Falls were also high on the list, resulting in six fatalities.
Also prevalent were:
- Surgical errors (especially wrong-site procedures and retained foreign objects)
- Medication errors
- Medical device malfunctions or misuse
- Lost or damaged biological specimens
These mistakes happened at clinics, surgical centers, hospitals and other health care facilities across the state.
Contributing factors
How do medical mistakes happen? Sometimes it boils down to the negligence of a single person. Other times, institutional shortcomings play a role. While numerous factors can contribute, the most common root causes in 2021, according to the report, were:
- Length of stay in ICU doubled since 2017.
- Took too long to put on personal protective equipment before being able to care for patient.
- Travel nurses and clinicians who were unfamiliar with Minnesota health care standards.
- Loss of strength due to increased length of stay leading to more falls.
There are few easy answers when it comes to solving the problem of medical negligence. One thing is certain, however: It’s a life-or-death issue that deserves our attention.
