Adverse Event Prevention

Medication Reconciliation

About 30 hospital representatives shared successes, barriers, models, tools, and other resources regarding medication reconciliation at MHA's "Medication Reconciliation: Exploring Issues Together" session on Tuesday, June 20, 2006.

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Standardized, colored wristbands for patients

Current variations in the use of color-coded "alert" wristbands may cause confusion among caregivers, staff, and patients and can lead to patient harm. The Minnesota Hospital Association recommends that all hospitals work toward reducing reliance on and eventually eliminating the use of color wristbands by collectively developing more effective ways to communicate emergency information and patient risks.

Following are resources for hospital staff to use in helping educate their caregivers about important policy changes in the use of wristbands.

• Wristband Implementation toolkit: [PDF]
• PowerPoint Presentation with talking points: [PPT]
• Sample Wristband Policy: [DOC]

For more information contact Tania Daniels, MHA vice president of patient safety, at (651) 603-3517.

Pressure Ulcer Prevention Protocol and Skin Safety Plan

Assessing, preventing and managing pressure ulcers are important goals for health care workers. A new protocol for pressure ulcer prevention was developed by the Institute for Clinical Systems Improvement (ICSI), working with the Minnesota Alliance for Patient Safety and wound care experts from across ICSI member organizations. See ICSI's Web page to download protocols and plans.

Safe Site Protocol for All Invasive, High Risk or Surgical Procedures

This protocol applies to all bedside and procedural areas within the hospital, ambulatory care centers and clinics. To download, visit the Institute for Clinical Systems Improvement Web page.

Falls Prevention Best Practices Resources

About 25 hospital representatives exchanged ideas on how to prevent patient falls at the Minnesota Hospital Association "Falls Prevention Day of Sharing" on Friday, April 14, 2006. Attendees discussed successes, challenges, models, tools, and other resources during the event at MHA's offices.

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Adverse Event Reporting

Guidance/Recommendations for AHE Reporting

The MHA Patient Safety Registry Advisory Council has been working with the Department of Health on addressing questions about definitions related to the adverse health event reporting law. Based on these discussions, MHA is offering these initial recommendations and guidance for AHE reporting. The purpose of these recommendations is to create more accurate and consistent reporting across organizations: [DOC] (Last update, January 2010).

Adverse Health Care Event Billing Policy

The Minnesota Hospital Association has been working with hospitals and payers to develop recommendations and guidance for implementing the serious reportable AHE Event Billing Policy: [PDF]. (Last updated September '08)

Reporting Template

This template can be used as a hospital policy for Adverse Health Event Reporting: DOC

28 Never Events

In 2003 Minnesota hospitals supported legislation to create a new reporting system for adverse events. The law gives Minnesotans better information about how well hospitals are doing at preventing 28 "never" events -- medical errors and other adverse events that should never occur. See list of events: [PDF].

Minnesota Adverse Health Care Events Reporting Act of 2003

This link contains the statute language of the Minnesota Adverse Health Care Events Reporting Act of 2003: (144.706-144.7069). This link contains the 2007 revised statute language of the legislation: [PDF].

Reporting adverse events

The 28 reportable events: [PDF] are reported to the Minnesota Department of Health through the Patient Safety Registry. For assistance or general questions related to the Patient Safety Registry, please contact Julie Apold at (651) 603-3538, toll-free at (800) 462-5393.

Communications

Communicating Outcomes to Patients

"Communicating Outcomes to Patients" [PDF] is model policy that provides suggested language and processes to use when communicating with patients and their families after an unanticipated outcome. This is a tool for health care facilities to use as a template when developing their organizational patient safety philosophy statements, policies, and procedures. The language may be modified to meet the needs of specific organizations.

Redefining the Culture of Patient Safety

This brochure describes the main concepts of how accidents occur, and how by changing our language, we can help create a culture where accidents are discussed and analyzed openly, objectively and honestly, without fear of blame or personal retribution. Brochures are 10 cents each, and quantities are available in groups of 100 only. To order, visit MHA's online store, or download an order form [DOC].