Minnesota Hospital Association

Patient Safety

Adverse Health Events Reporting

Minnesota hospitals are committed to doing all they can to prevent avoidable mistakes and improve patient care. Minnesota hospitals have championed an important improvement in how we track and report the most serious medical errors. Initiated by the Minnesota Hospital Association and the Minnesota Department of Health and created through state legislation in 2003, our system is the first in the nation to be built on the National Quality Forum's list of reportable adverse events (see below), including retained objects after surgery, serious medication errors, pressure ulcers and more.

Through hospital participation in the MHA Patient Safety Registry, hospitals report safety event and medical error information in order to share existing safeguards, identify common safety issues and facilitate new collaborative solutions among hospitals. Minnesota's approach goes beyond reporting; hospitals gain access to valuable information including benchmark reports and key learnings and action steps from peer hospitals.

The Minnesota Department of Health and MHA produce an annual report of adverse events in Minnesota hospitals, ambulatory surgery centers and regional treatment centers. The state's tenth public report on Adverse Health Events in Minnesota was released in January 2014.

Guidance for Adverse Health Care Event Reporting

The MHA Patient Safety Registry Advisory Council works with the Department of Health to address questions about definitions related to the adverse health event reporting law. Based on these discussions, MHA offers these recommendations and guidance for AHE reporting. The purpose of these recommendations is to create more accurate and consistent reporting across organizations. MHA has also prepared guidance to help facilities determine whether an event constitutes "serious injury."

Template for Adverse Health Care Event Reporting Policy

This template can be used to develop a hospital policy for Adverse Health Care Event Reporting.

Adverse Health Care Event Billing Policy

In September 2008, Minnesota became the first state to announce a statewide approach to billing for care made necessary by an adverse event. MHA worked with hospitals and payers to develop recommendations and guidance for implementing the serious reportable AHE Event Billing Policy.

Reportable Events Under Minnesota’s Adverse Health Care Events Reporting Law

These events have been adopted from the National Quality Forum’s list of serious reportable events. Download a printable fact sheet from the Minnesota Department of Health with language directly from Minnesota statute 144.7065.

Surgical Events

  1. Surgery or other invasive procedure performed on a wrong body part.
  2. Surgery or other invasive procedure performed on the wrong patient.
  3. The wrong surgical or other invasive procedure performed on a patient.
  4. Retention of a foreign object in a patient after surgery or other invasive procedure.
  5. Death during or immediately after surgery of a normal, healthy patient.

Product or Device Events

  1. Patient death or serious injury associated with the use of contaminated drugs, devices, or biologics provided by the facility.
  2. Patient death or serious injury associated with the use or function of a device in patient care in which the device used or functions other than as intended.
  3. Patient death or serious injury associated with intravascular air embolism that occurs while being cared for in a facility.

Patient Protection Events

  1. A patient who does not have decision-making capacity discharged to the wrong person.
  2. Patient death or serious injury associated with patient disappearance.
  3. Patient suicide, attempted suicide or self harm resulting in serious injury or death while being cared for in a facility.

Care Management Events

  1. Patient death or serious injury associated with a medication error, including, but not limited to, errors involving the wrong drug, the wrong dose, the wrong patient, the wrong time, the wrong rate, the wrong preparation, or the wrong route of administration
  2. Patient death or serious injury associated with unsafe administration of blood or blood products.
  3. Maternal death or serious injury associated with labor or delivery in a low-risk pregnancy while being cared for in a facility.
  4. Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy.
  5. Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a facility.
  6. Stage 3, 4 or unstageable pressure ulcers acquired after admission to a facility.
  7. Artificial insemination with the wrong donor egg or sperm.
  8. Patient death or serious injury associated with a fall while being care for in a facility.
  9. The irretrievable loss of an irreplaceable biological specimen.
  10. Patient death or serious injury resulting from the failure to follow up or communicate laboratory, pathology or radiology test results.

Environmental Events

  1. Patient death or serious injury associated with an electric shock while being cared for in a facility
  2. Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances.
  3. Patient death or serious injury associated with a burn incurred from any source while being cared for in a facility.
  4. Patient death or serious injury associated with the use or lack of restraints or bedrails while being cared for in a facility.

Potential Criminal Events

  1. Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider.
  2. Abduction of a patient of any age.
  3. Sexual assault on a patient within or on the grounds of a facility.
  4. Death or significant injury of a patient or staff member resulting from a physical assault that occurs within or on the grounds of a facility.

Radiologic Events

29. Death or serious injury of a patient associated with the introduction of a metallic object into the MRI area.