The Adverse Health Events reporting system recorded a total of 314 adverse health events in Minnesota hospitals and ambulatory surgical centers last year. Overall, the report shows a decrease in medication errors, retained foreign objects and pressure ulcers, while there was an increase in falls, wrong body part surgical/procedural events, and patient protection events (suicides and elopements). There were 14 deaths and 89 serious injuries that resulted from the reported events.  

“We are disappointed to see an increase in deaths and patient harm. Each of these events affects a patient and a family, and we take each one very seriously,” said Lawrence Massa, Minnesota Hospital Association president and CEO. “Behind the numbers, though, there is a remarkable story of the great strides that Minnesota hospitals are making to continuously improve hospital quality and prevent adverse events from happening again.”  

Nine years ago, Minnesota hospitals joined with the Minnesota Department of Health to lead the way in becoming the first state to publicly report adverse health events. Minnesota hospitals are committed to transparency, public reporting and sharing what is learned to ensure that patients receive the best care possible.  

“Over the past five years, overall patient harm is trending down,” Massa said. “For example, for more than 900 days, hospitals had no retained objects in labor and delivery.”  

The adverse health events reporting system allows us to identify issues and share prevention strategies continuously, Massa added. In the past year, reports from hospitals to the reporting system triggered a safety alert from the Minnesota Department of Health and MHA that resulted in no eye procedures being done with the incorrect lens strength for 163 days.  

“Minnesota hospitals have taken very intentional steps to prevent all adverse events, not just those that result in serious harm as reflected in this report,” Massa said. The Minnesota Hospital Association’s call-to-action framework has been a successful model to prevent adverse health events. For example:

• Data collected by MHA is showing a 31 percent decrease in falls across all levels of patient harm.
• The reporting system identified that pressure ulcers were happening under devices such as cervical collars and oxygen tubing and masks. In early 2011, MHA expanded its SAFE SKIN campaign to provide best practices for hospitals to prevent device-related pressure ulcers. This year, the most serious pressure ulcers declined 8 percent. Overall, hospitals have experienced a 45 percent reduction in stage II – unstageable pressure ulcers.  

“Minnesota has been a leader in developing innovative programs to improve patient safety and deliver quality health care,” said Jennifer Lundblad, president and CEO of Stratis Health, a quality improvement organization. “In our collaborative environment, we have combined resources across the health care community to build greater momentum for improvement. Together, we’ve used the science of human factors to understand what leads to errors, fostered organizational culture that focuses on safety, and developed comprehensive programs to prevent adverse events.”  

The adverse events described in this report are extremely rare. Minnesota hospitals and ambulatory surgical centers performed 2.5 million surgeries and procedures last year and provided care for roughly 2.6 million patient days — the cumulative number of days patients received care.  

The Minnesota Hospital Association, in collaboration with other health care partners, will continue to help hospitals create a culture of safety through best practices that expands across health care settings and serves as a foundation for successful patient safety and quality improvement efforts. Minnesota’s leadership on patient safety and quality is recognized throughout the nation, and other states look to us in creating their own patient safety programs.  

“Despite the exceptional work that is taking place in our hospitals, we know there is more work to be done,” said Massa. “We will continue to challenge ourselves to do better and we will share learnings from these events to help identify and implement best practices to prevent these types of events from reoccurring.”  

Get a copy of the report at http://www.mnhospitals.org/patient-safety/adverse-health-events/annual-report

Learn more about hospital patient safety at http://www.mnhospitals.org/patient-safety