Minnesota Department of Health Services Releases 2006 Report

Since 2003, Minnesota hospitals, ambulatory surgical centers, and regional treatment centers have been required to report whenever one of 27 serious events takes place. These events include falls that are associated with a death, foreign objects left in the body after surgery or other invasive procedures, and surgery or other invasive procedure on the wrong person or body part. Between October 7th, 2005 and October 6th, 2006, 154 events were reported to the Minnesota Department of Health (MDH).

The number of reported events might be higher or lower at a specific facility for a variety of reasons. A higher number of reported events does not necessarily mean that a facility is less safe. Facilities vary not only by size but also in the number and type of procedures that are conducted each year and in the type of patients seen; this can lead to fluctuations in the number of events reported. In some cases, the number of events may be higher at facilities that are especially vigilant about identifying and reporting errors. The reporting system itself may also have an effect, by fostering a culture in which staff at all levels feel more comfortable reporting potentially unsafe situations without fear of reprisal. It is important to note that in these cases, higher numbers may represent a positive trend towards greater attention to adverse events, their cause and prevention.

Improving patient safety is a long-term process, and there is still much work to be done. Initiatives like the Adverse Health Events Reporting Law help to focus attention and energy on preventing the most serious adverse events and harm to patients, but it is important to remember that this reporting system is just one component of a broader patient safety movement in Minnesota. Comprehensive efforts to reduce adverse events are underway nationally and here in Minnesota, and the effects of these efforts are being seen in the increased adoption of best practices by facilities and the increased focus on transparency and learning. Consumers and patients should use reports like this one to increase their awareness of patient safety issues and let their health providers know that patient safety and adverse event prevention strategies are a priority for them. This awareness and attention will help ensure that patient safety will continue to be a priority for hospitals, surgical centers and other health providers in Minnesota.