Adverse Medical Events Decline in Minnesota

The number of avoidable adverse events in Minnesota hospitals and ASCs has declined, thanks in part to statewide focus on reporting and analyzing the root causes of errors. The Minnesota Department of Health reported last week that 125 adverse events occurred in 38 hospitals and four surgical centers between Oct. 7, 2006 and Oct. 6, 2007, a decline of 29 events from the previous reporting period. The latest report noted stage-three or stage-four pressure ulcers (43), wrong-site surgery (24), and foreign objects left in patients after surgery (25) as the most frequently occurring adverse events.

Minnesota hospitals, surgery centers and regional treatment centers are required to report adverse events to the Department of Health. They must also indicate the causes of each event and actions taken to prevent similar events from happening again. Summaries of the reported events are published in newsletters that detail best safety practices, including promoting a team approach for wrong-site surgery prevention and encouraging clinical team members to speak up when safety measures are ignored.

"We must never lose sight of the fact that every adverse event had an impact on a patient and their family," says Sanne Magnan, MD, Minnesota Commissioner of Health. "Our reporting system, however, is revealing important results. Minnesota hospitals and surgical centers continue to develop and improve strategies to identify, analyze and prevent adverse events. The knowledge gained from this process is helping to improve the overall safety of care in Minnesota."

Daniel Cook

How Necessary is Ear Tube Surgery?

Ear tube insertion is one of the most common pediatric surgeries, but research suggests that many patients may not need to undergo the procedure. A study published in the January issue of the journal Pediatrics reported evidence of significant deviations between clinical practice guidelines and the variables physicians rely on when considering the need for surgery.

For the study, researchers at the Mount Sinai School of Medicine in New York City reviewed the case histories of 682 children who had tympanostomy tubes implanted in five area hospitals in 2002.

The American Academies of Pediatrics, Family Physicians and Otolaryngology-Head and Neck Surgery each recommend that ear tubes should not be inserted unless a patient has suffered fluid in the ear for three or four consecutive months. However, researchers found that in half of the cases reviewed, patients underwent the surgery after having shown fluid for less than three months during the year before surgery.

"This study of practice in the metropolitan New York area," the researchers write, "suggests that clinicians use variables other than those generally studied - duration of effusion, number of recurrent infections, hearing loss, speech delay, otoscopic findings, disruptions of family life, and presence of congenital or genetic defects - when deciding whether to insert tubes in children."

In the article, researchers wonder whether this deviation from clinical guidelines tends to be the norm nationally, and if so, why. "If our findings are generalizable, then they would be particularly troubling because otitis media is the most common illness with which children present to the doctor."

David Bernard

New York Cracks Down on Office-based Surgery

Facilities that offer office-based procedures in New York now have to report adverse events and must become accredited by July 14, 2009, due to legislation that went into effect last week. Hospitals are exempt from this legislation, but other facilities that use deep sedation or general anesthesia may be affected, according to the New York State Department of Health, including those offering gastrointestinal endoscopy, bronchoscopy, rhinoplasty, liposuction and mammoplasty.

The new law defines adverse events as a patient's death with 30 days; an unplanned transfer to a hospital; an unscheduled hospital admission for longer than 24 hours within 72 hours of the surgery; or any serious or life-threatening event. Facilities must report these events to the Department of Health within one day of learning of the event.

Nathan Hall

News and Notes

  • A WII IN THE SURGEONS' LOCKER ROOM? Sure, why not? A small study found that surgical residents who played certain video games on the Nintendo Wii video game system for an hour scored nearly 50 percent higher on tool control and overall performance in a virtual reality simulator. Researchers created a specially-rigged controller from the golf club add-on for the Wii. They cut off most of the golf club and attached a laparoscopic probe. Which game best replicates the delicate and precise movements that complex laparoscopic cases require? Marble Mania, which requires each player to use the motion-sensitive Wiimote game control to guide a ball through a 3-D maze, say researchers at the Banner Good Samaritan Medical Center in Phoenix, Ariz.

  • THE FBI RAIDED THE OFFICES AND HOME OF KAMAL TIWARI, MD, in December, according to the Times-Mail of Bedford, Ind. Last year, the anesthesiologist, who co-founded a hospital in Bloomington, Ind., had been accused of using multi-dose syringes on more than one patient during surgery, which created an infection scare among 2,500 patients in the Bloomington area. Now the FBI is investigating potential Medicare and Medicaid fraud on Dr. Tiwari's part, including double billing, upcoding and providing medically unnecessary services. Most recently, Dr. Tiwari has been practicing at the Pain Management Center of Southern Indiana and the Pain Management and Surgery Center of Southern Indiana.

  • ASCs IN MASSACHUSETTS may be subject to stricter oversight and required to contribute to the state's free-care pool if Senate Bill 1318 passes. This legislation, which is a repeat bill from last year, would require ASCs to be licensed by the state's health department and go through a "determination of need" process before being approved. The bill has had its first hearing, but no further action has been taken yet.

  • CATARACT SURGERY IN PARKING LOTS may become a staple of British healthcare. The BBC reports that new surgery and MRI centers on wheels will include admissions areas, full procedure rooms and recovery units. The health agency operating the mobile units says the program will offer surgical services where people work and live. The mobile centers will provide quality care for patients who previously had to travel great distances to receive treatment.
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