Minnesota hospitals take intentional steps to prevent adverse health events





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.