Progress made in preventing falls, other types of events

The number of adverse health events in Minnesota hospitals decreased slightly in the last year, indicating progress has been made in addressing some of the most common system breakdowns that lead to such events.

The Minnesota Department of Health's sixth-annual adverse health event report, released Thursday, showed a 3.5 percent reduction in events -- from 312 in the last reporting year to 301.

Patient falls resulting in serious disability or death decreased 20 percent in the reporting period, from October 2008 to October 2009. And no patients died as a result of a fall. In fact, the overall number of AHE-related deaths decreased to four, down from 18.

The report shows that Minnesota hospitals are continuing to make strides in patient safety, said Minnesota Hospital Association (MHA) President and Chief Executive Officer Lawrence Massa.

"Hospitals' efforts to prevent adverse events are clearly reaping rewards," Massa said. "But we have more work to do, and Minnesota hospitals will not let down their guard."

The study identifies instances at hospitals and ambulatory surgical centers where any of 28 types of adverse events occurred.

Minnesota hospitals were the first in the nation to champion a reporting law that called for such transparency. And Minnesota hospitals continue to lead the nation by collaborating to prevent the top four most-reported types of events: pressure ulcers, wrong-site surgeries, retained foreign objects and falls.

For example, more than 100 hospitals are participating in MHA's five patient safety Calls to Action campaigns that provide hospitals with a roadmap for implementing clinical best practices for prevention.

Minnesota Commissioner of Health Dr. Sanne Magnan has at least partly attributed this year's 20-percent decrease in falls to MHA's SAFE from FALLS campaign. More than 100 hospitals are taking part in that initiative.

When the FALLS campaign began in 2007, the average hospital had implemented fewer than 60 percent of recommended best practices. Today, that figure is greater than 90 percent. And for some of its steps, such as establishing a system to alert staff about patient risk, the implementation rate is nearly 100 percent.

Overall, anecdotal examples show that hospitals are also using creative methods to combat adverse health events. During a recent remodel, for instance, St. Michael's Hospital in Sauk Centre posted ceiling signs reminding patients to "call not fall" when they need to get up. In addition, many facilities have installed lower beds. And some now use bedside floor mats for at-risk patients to reduce injury if those patients do fall.

Statewide, hospitals are also implementing strict criteria for monitoring patients that fall to make sure that they have not sustained a head injury. Head injuries are not always detectable immediately after a fall, and patients' conditions can deteriorate quickly.

Hospitals and surgical centers across Minnesota are very committed to preventing adverse health events, said Diane Rydrych, assistant director of the MDH Division of Health Policy.

"While we may never be able to eliminate every adverse event, many people are working very hard to learn from past events and make future events as rare as possible," she said in an MDH news release.

For more information about MHA's patient safety efforts, visit the MHA patient safety area of this site or contact Tania Daniels, MHA vice president of patient safety, at (651) 603-3517 or Julie Apold, MHA director of patient safety, at (651) 603-3538.

View the MDH report here: [PDF].