January 23, 2014
Minnesota sees encouraging progress at 10-year anniversary of hospital safety effort
Number of adverse health events in Minnesota fell in 2013, deaths and harm about the same
Deaths and patient harm related to adverse events in hospitals and other facilities have been trending in a downward direction during the 10 years that the Minnesota Department of Health has required hospitals to report on preventable errors.
On Thursday, MDH released two reports, the Adverse Health Events in Minnesota Report, January 2013, and the 10 Year Adverse Health Events Evaluation Report. 2013 marks the 10-year anniversary of Minnesota’s Adverse Health Events reporting system that tracks 28 types of serious events, such as wrong-site surgeries, severe pressure ulcers, falls, or serious medication errors, which should rarely or never happen. Before the system was launched, there was no statewide system for assessing how frequently preventable errors such as these happened in hospitals or ambulatory surgical centers.
The Minnesota Department of Health used the 10-year anniversary as an opportunity to explore whether the effort has made Minnesota’s hospitals and surgical centers safer. "Our evaluation confirmed that this joint effort between MDH, its partners, and Minnesota’s health care facilities has helped to shine light on what was often a hidden problem," said Minnesota Commissioner of Health Dr. Ed Ehlinger. "By doing so, it has not only contributed to better outcomes, faster responses, and better practices, but it has also resulted in a significant change in mindset, from acceptance that some errors are unavoidable to an expectation that those errors can be prevented."
Leaders and staff at hospitals and ambulatory surgical centers said when surveyed that their facilities have increased awareness of patient safety and are generally safer than they were 10 years ago. In 2008, after being asked to reflect on the environment prior to the passage of the law, only 33 percent of staff surveyed rated the priority of patient safety as "very high" in 2003 compared to 69 percent in 2008, and 69 percent again in the 2013 survey.
"Our 10-year evaluation supports the adverse health events reporting system as a way to learn, share findings, and continuously improve patient safety and quality of care," said Lawrence Massa, president & CEO of the Minnesota Hospital Association. "When events happen and safety alerts and best practices are issued, Minnesota hospitals respond immediately to implement new patient safety practices."
The evaluation survey results also support health care worker perceptions that hospitals and surgical centers are safer. MDH found that harm from adverse health events, has been trending downward over the 10 years. The number of annual deaths has varied from year to year but has been moving in a downward direction from a high of 25 in 2006 to a low of 5 in 2011. The number of events resulting in serious disability has also followed a downward trend from nearly 100 in 2008 to 84 in 2013. Note, a definition change occurred in 2007 that invalidates some comparisons before and after that year.
Likewise, there have been positive changes in the number of adverse health events related to surgeries and invasive procedures, including wrong-site surgeries and objects left in patients after surgeries. In 2011, there were 89 of these events compared to 61 this year. Health facilities have also significantly decreased the time between when an adverse event occurred and when it was discovered from more than 60 days in 2003 to less than 10 days in 2013.
In the tenth year of reporting, the total number of events reported under the law was 258, a decline of 18 percent from the previous year, according to the annual Adverse Health Events Report. This was the first time the total number of events fell below 300 since definitional changes in 2007 that broadened reporting, and is the largest year-to-year drop since the inception of the reporting system. The drop was mostly driven by a 35 percent decline in pressure ulcers.
However, the decline in total number of events in 2013 did not result in a decline in the number of deaths for 2013. There were 15 deaths in 2013, with the reporting year defined as October 2012 to October 2013. Of the 15 deaths during that time period, 10 were related to falls. In fact, reducing falls and reducing harm from falls continues to be one of the most difficult hazards to eliminate, despite significant focus and adoption of best practices by health care facilities as well as MDH and MHA issuing a safety alert around identifying injury risk factors for falls in May 2013.
The report also notes overall adverse events are rare considering that in 2012 Minnesota hospitals and ambulatory surgical centers performed 2.6 million surgeries and procedures.
Moving forward, the 10 year evaluation calls for Minnesota to develop additional training opportunities for the most reported events, develop new methods and tools that facilities can use to share data, and work to expand the same commitment to transparency, learning and public reporting to other health care settings, such as long-term care facilities and clinics.
"Overall, the 10-year look back shows encouraging progress as does parts of the 2013 report," said Diane Rydrych, director, MDH Health Policy Division. "But the fact that harm did not decrease in 2013 shows that this is also the sort of work that is never done and requires constant attention."