February 26, 2015
Health department report measures adverse health care events
Tracking hospital incidents helps medical professionals identify patient safety strategies
The Minnesota Department of Health released its 11th annual Adverse Health Events report Thursday as part of its nation-leading hospital and surgical center safety program.
As a result of the program, hospitals have recently taken a number of steps to prevent adverse events related to violence, falls, surgical care and other issues. In addition, year the system tracked four new types of adverse events in 2013-2014 in an effort to further improve patient safety. Those additions are leading to new learning related to the loss of biological specimens and improving communication of test results.
"The addition of these new events highlight that the core of Minnesota's hospital safety effort is to always keep striving for additional improvements and new opportunities to protect patients," said Minnesota Commissioner of Health, Dr. Ed Ehlinger.
The new reportable event categories for the October 2013 to October 2014 reporting period are as follows:
- Death or serious injury resulting from failure to follow up or communicate laboratory, pathology or radiology test results - 5 events.
- Irretrievable loss of an irreplaceable biological specimen - 20 events.
- Neonatal death or serious injury associated with labor and delivery in a low-risk pregnancy - 6 events.
- Death or serious injury of a patient associated with the introduction of a metallic object into the MRI Area - 0 events.
Including these new categories, Minnesota hospitals and surgical centers reported 308 adverse health events, including 98 serious injuries and 13 deaths, during the October 2013 to October 2014 reporting period. Without the new events, facilities reported 277 adverse events, including 92 serious injuries and eight deaths. This was an improvement over the number of deaths recorded last year. In last year's report, facilities reported 258 events, 84 serious injuries and 15 deaths.
"The adverse events reporting system provides a strong system for learning and improvement," said Lawrence Massa, president and CEO of the Minnesota Hospital Association. "In the 15 years that Minnesota's hospitals have been spearheading patient safety efforts, they have shown a remarkable commitment to improving patient safety and the addition of these new events demonstrates that commitment to continuous improvement."
A total of 28 states track adverse events but only 3 states publicly report events at a facility level including Minnesota, New Hampshire, and Colorado.
Minnesota added the four new event categories to Minnesota's Adverse Health Events law in 2013 to align with the National Quality Forum's adverse health events. The newly added neonatal measure intends to capture cases where there is an infant death or a serious injury during labor and delivery in low risk pregnancies. Out of the 65,000 births during the time-period, this situation happened six times. In most cases, a thorough analysis by the facilities did not find a clear reason why the deaths or injuries occurred, which underscores the complexity of these cases.
The most frequently reported events were pressure ulcers (107) and falls associated with serious injury or death (79). The next most frequently reported events were foreign objects left in patients after surgery or an invasive procedure (33). This year saw a decrease in sponges, gauze and packing materials left in patients but an increase in identification of small fragments, instruments or wires.
The ultimate goal of the adverse reporting system is to use data to identify and implement best practices that improve patient safety. As a direct result of this system, MDH and its partners took a number of steps to prevent adverse events, such as the formation of a violence prevention work group and fall prevention recommendations related to anticoagulation therapy and safer patient rooms, bathrooms and toileting procedures.
In 2015, expected patient safety improvement efforts include piloting strategies for reducing lost or damaged biological specimens, the identification and implementation of best practices for improving test result communications, and more effectively identifying fragments of instruments and wires to reduce the number of them left in patients. Work will also continue to address perinatal safety and to partner with surgeons and interventional radiologists to improve correct spine level surgery and spinal injections.
The full report is available at https://www.health.state.mn.us/facilities/patientsafety/adverseevents/consumer.html.