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MN error reports show 20 patient deaths in 15 months

Quality Improvement Monitor, January 27, 2005

Twenty patients died in Minnesota hospitals during a 15-month period because of medical errors including falls, faulty medical equipment, and administering the wrong medication, according to a report from the state Health Department released January 19.

The report showed 99 serious errors between July 1, 2003, and October 6, 2004. The Washington, DC-based National Quality Forum developed the reporting standards, and Minnesota is the first state to report errors based on them.

New Jersey and Connecticut also adopted the standards, and other states are considering them as well.

St. Luke's Hospital in Duluth reported four deaths related to medical errors, the most in the state. The causes were a fall, a medication error, a malfunctioning medical device, and a burn.

Three patients died after medical errors in Mayo Clinic facilities in Rochester and Mankato, including two who received incorrect medications and one apparently healthy patient who died after an operation.

The most common mistake that did not result in death was physicians forgetting objects such as surgical sponges inside patients at the end of operations, which occurred 31 times.

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