Article From Minnesota Department of Public Health

The number of adverse events reported in the past year is higher than it was the year before. Many states that have reporting systems like this one have seen the same thing that we see here in Minnesota. Numbers often go up for at least a few years after a reporting system starts. However, since there are millions of visits to hospitals and ambulatory surgical centers each year, the rate of adverse events per 100 or 1,000 visits hasn’t changed measurably. The odds of an event happening to you haven’t gone up. These events are still very, very rare.

Most likely, the numbers have gone up because there is now lots of attention being paid to identifying and reporting events. Facilities now know that they can report their events in a safe environment that is focused on learning. This makes them feel more comfortable reporting events that happen, and sharing what they’ve learned from them. This safe environment is an important part of the adverse events reporting system.  When hospitals focus on what caused an event to happen, and if they can learn enough from it to prevent it from happening again, patient safety improves. It’s hard to look at these numbers, because these events should never happen. But it’s important to remember that if we don’t know about these events, we can’t fix the problems that caused them.

For every event that is reported, a team of people at the hospital or surgical center ask questions about what factors led up to the event. Their answers might be about training, staffing levels, equipment, communication, environmental issues, or other factors. Then, they design actions to address those problems and prevent the event from happening again. MDH also works with a team of experts to analyze each event and make sure that this process, called Root Cause Analysis, was complete and thorough. We also look at all reported events to find common problems that might be leading to events. Then, we work to educate facilities about these problems through newsletters, training, safety alerts, and other methods.