The Minnesota Health Department Releases Second Annual Report

The Minnesota Department of Health (MDH) today released its second annual report on preventable adverse events in Minnesota hospitals. This year’s report also includes adverse events that occurred in ambulatory surgical centers. Preventable adverse events include such things as wrong-site surgeries, pressure ulcers, retained objects after surgery, death or serious disability from a medication error, and death from a fall. “Our adverse health events reporting system provides us with a wealth of information that health care facilities can use to improve patient care,” said Minnesota Commissioner of Health Dianne Mandernach. “As a result of last year’s report, we were able to identify areas of concern and begin addressing them through several statewide patient safety initiatives. With this year’s report, we will have even more information to help us develop strategies for preventing adverse events.” The report notes that the most frequently reported event was a stage three or four pressure ulcer (serious bed sores); the next most frequently reported event was a foreign object left in a patient after surgery. Roughly half of the “wrong body part surgery” reports occurred during surgeries involving the knees or chest.

In addition to reporting individual events, facilities are required to report on the underlying cause of each event and the corrective actions being taken to prevent similar events from happening in the future. This reporting system provides a forum for sharing the reported information with hospitals and surgical centers across the state so they can learn from one another. Generalized information from the adverse health events reporting system is also shared with facilities through newsletters highlighting best practices, safety alerts and presentations throughout the year. Armed with new information about adverse events, Minnesota’s hospitals and surgical centers are implementing a variety of proven strategies for preventing many types of errors. Such strategies include developing new ways to track objects used in surgical procedures; ensuring that procedures for counting those objects are thorough and consistent throughout a facility; expanding policies both inside and outside the operating room to ensure correct site surgery; improving how patients are assessed for the risk of falling or developing a serious pressure ulcer; and using labeling or color-coding to flag high-risk medications. “Minnesota’s hospitals are pioneers in finding new ways to improve patient safety,” said Bruce Rueben, president of the Minnesota Hospital Association. “For example, our data sharing showed us that pressure ulcers were the highest reported event. Hospitals took action, convened wound care experts from across the state and worked on the development of the first protocol of its kind for preventing pressure ulcers in an acute care setting.” The legislation creating the adverse health event reporting system was championed by Minnesota hospitals and was signed into law by Gov. Pawlenty in 2003.

The law requires all Minnesota hospitals and ambulatory surgical centers to report to MDH whenever any of 27 events occurs. The National Quality Forum, a Washington, D.C.-based health care standards-setting organization, created this consensus-based list of adverse events in 2002 at the request of the federal government. This followed an Institute of Medicine report estimating that medical errors in hospitals cause 44,000 to 98,000 deaths every year in the U.S. Minnesota’s first adverse events report, published in January, 2005, summarized events that occurred in hospitals only during the start-up period of the law, between July 2003 and October 2004. Surgical centers were required to begin reporting in December 2004. Mandernach suggested that consumers should use information in the report to become more involved in their health care. “Consumers should use this report to identify situations of interest to them and then ask their health care providers what they’re doing to provide the safest care possible,” Mandernach said. Mandernach added that it is difficult to compare facilities using just the numbers in the report. “The errors documented in this report are a very small fraction of all the procedures and admissions in Minnesota hospitals and surgery centers,” Mandernach said. “Alone, these numbers are not useful or relevant for comparison purposes, yet we realize that one error is one too many. The power of our reporting system lies in looking at events across organizations so that we can learn how events occurred and aggressively implement steps to prevent them from happening again.” Approximately 2.1 million patients are admitted to Minnesota hospitals or seen in a hospital emergency department each year, while an additional 450,000 receive same-day surgery at Minnesota hospitals and surgical centers.