Minnesota hospitals cut serious drug errors after years of efforts

Sandra Hall entered the HealthPartners Same Day Surgery Center in St. Paul to fix arthritis in her left thumb. When she left, in an ambulance, she was unresponsive and her heartbeat was unstable.

A medication error allegedly caused the 67-year-old Vadnais Heights woman to enter cardiac arrest before her routine surgery in December 2022. A lawsuit claims anesthesia meant for the nerves in her hand was injected instead into her bloodstream.

“We made a mistake,” a doctor told Hall’s family, according to the suit filed in Hennepin County District Court against HealthPartners and the anesthesiologist who administered the medication.

Medication errors have been a leading cause of preventable deaths and disabilities in Minnesota hospitals and surgery centers in the 21 years since they started publicly reporting their own adverse events. A record 25 medication errors were reported statewide in a 12-month period ending in October 2023. Three caused patient deaths and 22 led to disabling injuries.

Hall endured multiple cardiac arrests after the alleged medication error, but survived after she was transported to a hospital and placed on a heart-lung bypass machine. She returned home with neurological problems including cognitive disruptions, headaches, mood disorders and balance problems, according to the lawsuit she filed in April.

“When you go into cardiac arrest the amount of times that she did, blood’s not getting to your brain,” said J. Ashwin Madia, one of Hall’s attorneys. “That can have pretty catastrophic consequences.”

HealthPartners provided a statement Monday: “While we can’t comment on individual patients, our care teams are committed to a culture of safety — one that encourages speaking up, double-checking details, clear communication and continuous improvement."

The hopeful news for Minnesota is that its hospitals only reported 14 fatal or disabling medication errors in the 12-month period ending in October 2024, according to the latest hospital adverse event data released Tuesday by the Minnesota Department of Health.

Hospitals achieved a 44% decline from the prior year by recommitting to safety steps such as doublechecking prescriptions with colleagues or repeatedly scanning barcodes on patients’ wristbands to confirm a match to their prescriptions, said Rachel Jokela, director of the state health department’s adverse events reporting program.

Safety steps can feel like overkill for doctors, pharmacists and others who successfully carry out hundreds of prescriptions in a day without incident, but Jokela said they are designed to prevent the one-in-a-million nightmare scenario. All hospitals are at risk, considering that one medication error was reported this year at a small critical-access hospital in Cloquet and three were reported at the internationally renowned Mayo Clinic in Rochester.

“It’s a very small number based on the number of medication doses that are given in hospitals and surgery centers annually,” she said. “But this is an area that we have kept emphasizing year after year. We know the best practices. We know how to do them.”

In all, 624 adverse events were reported last year, including medication errors but also 28 other categories of preventable mistakes. The tally included 290 severe but preventable bed sores, 94 disabling or fatal falls, and 45 surgeries in which sponges, needle fragments or other items were left inside patients.

Fourteen deaths last year were linked to adverse events. One involved a medication error at Methodist Hospital in St. Louis Park and another resulted from the failure to communicate test or lab results to a patient at Abbott Northwestern Hospital in Minneapolis. Four were caused by patient falls and four by malfunctioning medical devices.

The latest total represents a slight increase from 610 adverse events in the prior year, but Jokela said that might be progress. Adverse events had spiked 70% since 2019, partly because hospitals struggled with staffing shortages and other pressures during the COVID-19 pandemic, she said.

Minnesota in 2004 became the first state to publicly report adverse events by the hospitals at which they occurred and to organize a system by which hospitals shared lessons from their mistakes in the hopes that others would avoid them.

Whether the allegations in Hall’s lawsuit represent an adverse event in the state database is unclear. The incident occurred in a year in which HealthPartners’ Regions Hospital disclosed a medication error, and the St. Paul hospital oversees the surgery center at which the alleged mistake occurred.

However, the details of adverse events aren’t disclosed beyond their categories and the hospitals that were involved. They are even shielded from use in lawsuits to ensure hospital leaders can speak freely about mistakes and help others avoid them.

Madia said he believes there were multiple missed opportunities to prevent Hall’s cardiac arrest, beyond injecting the anesthesia in the proper location. The anesthesiologist in the case could have injected the medication in phases, rather than all at once, to see how his patient tolerated it. The doctor also could have withdrawn the needle to check for bleeding to indicate that the injection was misplaced, the attorney said.

Hall hadn’t expected any trauma. She had the same procedure without incident on her right hand. Her son was waiting in the parking lot outside the surgery center to take her immediately home. He walked into the clinic and discovered his mother’s cardiac arrest.

Almost half of Minnesota’s reported medication errors two years ago involved incorrect administration, such as giving medication at the wrong injection site, but that rate declined last year. Instead, two-thirds of the medication errors last year involved issuing incorrect prescriptions. Jokela said that can be a problem in an era of electronic medical records when doctors can make mistakes just by hovering over the wrong drugs in a dropdown menu.

“That could be the new frontier” of prevention efforts, she said.

The Minnesota Hospital Association has a safety committee specifically focused on medication errors. A recent focus area has been on medication reconciliation, or making sure that patients continue to take the right medications as they make transitions in and out of hospital care.

“We always want to see a reduction in adverse health events, because every event is important and represents a patient,” said Jennifer Schoenecker, the association’s vice president of quality and safety.

The 621,205 surgeries last year represented an 8% increase from the prior year, and created more opportunities for errors. The state reported 34 surgeries last year to the wrong body part — such as operating on the left side of the body rather than the right — and 30 surgeries in which the wrong procedures were performed. Both were increases from the prior year.

“We really want to try to get those numbers down,” said Jokela, adding that “the goal here is zero.”