Adverse Health Events Reports and Fact Sheets
MDH publications and reports on patient safety and adverse events.
Report: Adverse Health Events in Minnesota Annual Report 2022 (PDF)
Report: Adverse Health Events in Minnesota-Dec 2020 (PDF)
Notice: Due to the unprecedented COVID-19 pandemic, many state employees have been redeployed to assist with pandemic response. This has impacted our ability to release certain legislatively-mandated reports, including the annual Adverse Health Events (AHE) report. Prior to COVID-19, MDH had spent over a year gathering input on how to advance the system to better support safe patient care in a rapidly evolving, complex health care environment. Through extensive outreach, the project’s steering team had identified some high-level themes and recommendations that will help to guide our work to evolve the system. A discussion of that work, and the resulting recommendations, is a strong focus of this report. However, with COVID-19 continuing to strain our health care delivery system, individuals, and communities, it is likely that the new landscape of health care will look different, in significant ways, than it did prior to the pandemic. MDH is committed to re-convening our partners post-pandemic to assess how these recommendations for evolution apply in this new environment, and whether they need to be modified.
The 2021 annual Adverse Health Events report will also not be released in the same manner as in the past. For the 2021 annual report, the data will be released with little or no accompanying narrative. Throughout 2020, MDH has continued to contract with the Minnesota Hospital Association and Stratis Health to manage the patient safety registry, analyze data and trends in adverse health events, and review submitted events to ensure reporting, root cause analysis, and follow-up requirements are being met. There has been no lapse in the reporting requirements for hospitals and ambulatory surgical centers.
Adverse Health Event data by facility
Minnesota Legislative Reference Library: Adverse Health Events in Minnesota Reports 2005 - Present
Suicide Prevention in Health Care Facilities: Environmental Safety Recommendations (PDF)
2015 Consumer Guide to Adverse Health Events (PDF)
Adverse Event Reporting 2009: 5 years later, where are we? (PDF)
Adverse Event Reporting 2014: 10 Year Program Evaluation (PDF)
Trends & Data
Spotlight on Patient Safety: Retained Foreign Objects, April 2009 (PDF)
Spotlight on Patient Safety: September 2008 (PDF)
Adverse Health Events Factsheet: Staffing and Patient Safety
Adverse Health Events Factsheet: Pressure Ulcers
Adverse Health Events Factsheet: Retained Objects
Adverse Health Events Factsheet: Wrong-Site Surgery
Fact sheet: Adverse Health Events Reporting in Minnesota: First Annual Public Report