Minnesota Hospital Association

Quality & Patient Safety

October 16, 2017
Five serious events and two deaths involving EPINEPHrine have been reported to the Minnesota patient safety registry (PSR) in the last four reporting periods. Minnesota is not alone in documenting very serious errors with EPINEPHrine. The Institute for Safe Medication Practices (ISMP) has recently issued two safety alerts for EPINEPHrine (Feb. 2015 and Aug. 2016).

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August 15, 2017
Although Minnesota hospitals and health systems have been working to reduce pressure ulcers/injuries, we continue to experience a high number of these adverse events, specifically those on the coccyx/sacrum. If this trend continues we will experience a high number of these events in reporting year 14 (2016-17). Improvement in the consistent implementation of best practices can help to reverse this trend and make a difference in the safe care of patients. We take this issue seriously because we know that these events are a safety concern for Minnesota patients, families and communities.

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June 30, 2016
Although Minnesota hospitals, health systems and surgical centers have been working diligently to reduce wrong site/wrong body part and wrong procedure adverse events, we experienced a high number of events in year 12 and may experience an even higher number of these events this year unless best practices are reviewed and consistently implemented.

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May 11, 2012
MHA and MDH issue an alert regarding wrong procedure events involving implants and issues with verification of the correct implant.

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April 22, 2010

The Minnesota Hospital Association (MHA) and the Minnesota Department of Health (MDH) have reviewed data from the adverse health event reporting system and have noted that in 38 percent of wrong site procedures reported since October 2009, the correct site was marked by the person performing the procedure, however, the site mark was not located, and its location shared with the procedure team, as part of the time-out process.

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January 15, 2009

Root cause identified in infant warmer fire

A team of nationally-recognized experts has concluded that the fire that occurred in an infant bassinet at Mercy Hospital on Jan. 22, 2008 was most likely caused by a hot particle falling from the bassinet’s warmer assembly into the oxygen-enriched environment near the infant’s head.

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January 09, 2007

MHA and MDH have reviewed data from the adverse health event reporting system and have noted a cluster of invasive eye procedures that have resulted in either the procedure being performed on the wrong eye or the wrong lens being inserted into the eye. Facilities have found that these events have occurred primarily due to inconsistent or ineffective processes for marking the correct eye and/or non-existent or ineffective verification/ “time-out” processes being followed prior to the regional block or procedure.

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July 31, 2006

Minnesota Hospital Association (MHA) has reviewed data from hospitals that have agreed to share adverse health reporting information and has noted commonalities in submitted root causes for wrong body part surgical events. The majority of root cause analyses indicate that a “Time-Out/Pause for the Cause” prior to the invasive procedure, regional block, or surgery was either not conducted or was not effectively conducted.

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July 21, 2005

A Minnesota hospital recently had an incident occur in which a Datascope MR Monitor was brought into the MRI room in preparation for conscious sedation.

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April 01, 2005

A telemetry device manufacturer had programmed a monitoring alarm function so it was in the “off” position and had not made this known to the hospital at the time of purchase. This “off” position prevents the alarm from signaling in the event of a low or failed battery or when the device’s leads become disconnected from the patient. 

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