Three reportable "adverse health events" occurred during 2009 at Fairview Red Wing Medical Center.

They were the first such events here in three years; two events were cited in the January 2007 report.

A new checklist of all the steps that need to be followed was created as a result of the events, according to Dr. Jack Alexander, chief medical officer.

"We're disappointed when we have events," he said, but Fairview sees them as an opportunity to learn and improve care.

"There's no question," he said: "Patient safety is on the top of everybody's mind. It's the first thing we attend to."

The three events were included in the Minnesota Department of Health's sixth annual adverse health events report, released on Thursday.

A total of 301 events were reported statewide between Oct. 7, 2008, and Oct. 6, 2009 - down from 312 events in the 2009 report. Four surgical centers and 58 hospitals out of a total 199 facilities reported events.

Fairview Red Wing's events fall in three of the 28 categories that must be reported. None of the events resulted in death or permanent disability, although one of them resulted in a serious disability of a temporary nature.

One involved a surgical/invasive procedure on the wrong site on a patient's body; one was the wrong surgical/invasive procedure; and the third event involved use or malfunction of a device in patient care. The hospital cannot comment on the individual cases, Alexander said.

He did, however, stress that "if an event causes harm to any patient, we don't consider it minor at all." The events were discussed in detail with the patients and their families.

"We do a root cause analysis," he said - an in-depth look at all factors that resulted in the error - very quickly following an event. "We need to understand it from every angle."

To do that, they bring together everyone involved, from doctors and nursing staff to pharmacists, lab employees and even the people responsible for the equipment and supplies.

The analyses are not limited to adverse events, Alexander pointed out. "We do up to eight a month," including things that went well, to pinpoint what is being done right.

One result, Alexander said, has been "universal protocols," which are implemented not only in the operating theater, but also other places where invasive procedures are done - the emergency department, patient floor, clinic and outpatient area.

"It can be a challenge" when things get busy, he acknowledged. Since the opening of a new surgical wing, "our volume has increased." The 50-bed facility had 25,641 patient days and performed 14,430 surgeries/procedures in the 12-month period.

But he did not attribute the increase in adverse events to the patient load. "There is some randomness to things that happen." Also, officials believe that facilities probably have become more rigorous regarding what they report, and the threshold of events being reported may be lower.

"Four or five years ago, people did not want to admit mistakes," Alexander said. Now they are more willing to talk about such things. "That's probably the most important piece about learning how to correct them."

Hospitals have been supportive of the state's adverse health events reporting from the start, officials said. The legislation creating the reporting system was championed by Minnesota hospitals and signed into law by Gov. Pawlenty in 2003.

The focus is not on what was done wrong, Alexander said, "but on what we can learn to try to improve. ... We have an incredibly talented and engaged staff," and all are accountable for patient safety.

Changes made as a result of the reports are proving effective, state officials say.

Minnesota Commissioner of Health Dr. Sanne Magnan noted a 20-percent decrease in falls and a corresponding increase in participation in the Minnesota Hospital Association's "Safe from Falls" campaign over the past two years.

This year, Magnan said, key lessons involve the need to prevent pressure ulcers in the operating room. Successful strategies will be shared with hospitals and surgical centers statewide.

A full copy of the adverse health events report and additional information can be found on health department's Web page at

The new report lists one other adverse event in this area. St. Elizabeth's Hospital in Wabasha reported one fall that resulted in a serious disability.