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.
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.”
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.
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
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.
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:
collected by MHA is showing a 31 percent decrease in falls across all
levels of patient harm.
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
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 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.
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
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
more about hospital patient safety at http://www.mnhospitals.org/patient-safety