January 31, 2013
Number of adverse health events in Minnesota hospitals stayed flat in 2012
Deaths and injuries rise, primarily due to falls
In its most recent annual report on adverse health events occurring in Minnesota hospitals and outpatient surgical centers, the Minnesota Department of Health found that the total number of adverse events stayed about the same compared to the year before, but more patients experienced serious harm or death related to these events. Most of the increase was related to serious falls. During the same period, the number of serious bedsores, retained foreign objects and medication errors decreased. The adverse health events reporting system report released January 31st, 2013 tracks 28 types of serious events, such as wrong-site surgeries, severe bedsores, falls, or serious medication errors, which should rarely or never happen.
There were 14 deaths in 2012 compared to five in 2011 and 89 serious injuries compared to 84 in 2011. While most of this increase was due to a higher number of serious falls, deaths related to suicides and elopements also increased slightly. Nearly 90 percent of the cases of harm or death were a result of falls. Over the life of the reporting system, falls, medication errors, and suicide have been the most common causes of serious patient harm or death.
This is the ninth year that Minnesota has produced the report that also found hospitals and surgical centers improved in several key areas during 2012;
- The number of total pressure ulcers (bedsores) declined by eight percent. This is the first decline of this magnitude in the nine years of reporting. This year's total of 130 is down from a high of 141 last year.
- Retained foreign objects declined by 16 percent. This is the first decline in this category in five years.
- Medication errors dropped by 75 percent from the previous year and were at the lowest level in all nine years of reporting.
- In response to an increase in implant-related wrong procedures, MDH collaborated with the Minnesota Hospital Association (MHA) to issue a safety alert, which provided key practices that should be implemented to improve the implant verification process prior to a procedure.
- As a result of the data showing a continued increase in reportable events due to the scheduling process, best practices for safe surgical scheduling and verification were rolled out through a statewide MHA campaign.
- Due to 25 percent of invasive procedure events occurring in radiology, a statewide campaign specifically targeted for improvement in radiology was rolled out.
- Exploring and piloting additional strategies for reduction of falls and fall injury, such as creating education, training and resources around linking specific fall risk factors with interventions.
- Working with hospitals and surgical centers on a targeted effort to prevent retention of broken/fragmented items as well as the accounting for, and handling of, packed items.
- Conducting a follow-up evaluation of the pre-procedure Minnesota Time Out process recommendations.
- Providing training to facilities on suicide prevention and violence to address issues uncovered this past year related to patients with behavioral health needs.
"This year's report shows that as a state we really need to redouble our efforts to reduce falls in hospitals," said Minnesota Commissioner of Health Dr. Ed Ehlinger. "While falls in health care settings can be very difficult to prevent, we also need to look at all opportunities to prevent injury when falls do occur, by focusing interventions on each patient's specific risk factors."
According to the report, in 2012 hospitals did a better job of identifying patients at risk for falling and checking on them at frequent intervals, but there is still work to be done in terms of creating tailored plans for each patient and sharing a patient's risk for falling with every member of the care team. Patients also need to be aware of the dangers of moving around without assistance.
In nearly 60 percent of falls, a care team member had completed a rounding visit with the patient within 30 minutes prior to the fall, to check on pain, position and toileting needs, but the patient then got up on their own to use the toilet.
Minnesota's reporting system has a strong focus on reporting, but also on learning. The overall purpose of the reporting system is to use the data that is gathered to identify issues and to learn from those issues, to prevent them in the future. Key lessons from 2011 that were acted upon in 2012 include the following.
MDH's goal, together with the Minnesota Hospital Association, Stratis Health and other partners, is to give clinical team members the resources they need to understand why these events happen, and how to prevent them.
"2012 was a mixed year, with overall events staying level but harm and deaths increasing. This tells us that we still have work to do if we want to eliminate preventable harm," said Diane Rydrych, director of the MDH Health Policy Division. "We have to make sure that we are focusing on evidence-based solutions rather than quick fixes, addressing workflow and organizational culture, and ensuring that leadership within each organization is fully engaged," Rydrych said.
Going forward, the key lessons from this year's events indicated a number of steps that MDH and its partners will take to improve patient safety in Minnesota, including the following.
Adverse events occur throughout the year with an average of about 26.2 a month or at a rate of about 12.1 per 100,000 total patient days. From October 2011 to October 2012, Minnesota hospitals reported 2.6 million patient days. In 80 percent of reportable events, the patients were hospital inpatients, 16 percent were in ambulatory surgical centers, and the remaining four percent were in the emergency department or another location in the facility.
The legislation creating the adverse health events reporting system was supported by Minnesota hospitals and signed into law in 2003. The law requires all Minnesota hospitals and ambulatory surgical centers to report to MDH whenever any of 28 serious events occurs. The National Quality Forum, a Washington, D.C.-based health care standards-setting organization, created this list of adverse events in 2002 following an Institute of Medicine report estimating that medical errors in hospitals cause 44,000 to 98,000 deaths every year in the United States.
A full copy of the adverse health events report and additional information can be found on MDH's Adverse Health Events Web page, at www.health.state.mn.us/patientsafety. More information about hospitals can be found at www.mnhospitals.org. Information about the Minnesota Alliance for Patient Safety is available at http://www.mnpatientsafety.org/.
Health Policy Division