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. Last year, that trend continued, with 341 total errors resulting in 103 injuries and 12 patient deaths.
Most prevalent types of mistakes
As in past years, bed sores (also called pressure ulcers) were the leading type of adverse event in 2017, 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 five fatalities. More than 70 percent of falls involved seniors aged 65 and older, and nearly a quarter involved patients with dementia.
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 2017, according to the report, were:
- Inadequate policies or procedures at an institutional level (32 percent)
- Lapses in communication or incomplete information (20 percent)
- Problems with equipment or facilities (11 percent)
- Insufficient training or education (10 percent)
In an alarming number of cases – 18 percent – no root cause could be identified, suggesting that gaps still remain in our understanding of how and why these events happen.
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.
