February 22, 2018
Health department releases annual adverse health events report
The number of reportable adverse events in Minnesota hospitals, ambulatory surgical centers and community behavioral health hospitals has been slowly increasing for the last four years, reaching 341 between October 2016 and October 2017.
Minnesota’s Adverse Health Events reporting system tracks 29 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 recent rise in adverse events is concerning,” said Health Commissioner Jan Malcolm. “Minnesota can and must do better to protect vulnerable patients. We will continue to work with our partners to improve patient safety and the quality of care.”
Of the reports submitted during this reporting period, 30 percent resulted in serious injury (103 events), while approximately four percent (12 events) led to the death of a patient, according to the Adverse Health Events in Minnesota 14th Annual Public Report.
Over the 14 years of the reporting system, falls, medication errors and product/device malfunction have been the most common causes of serious patient injury or death. The pattern was similar in 2017. Five of the 12 deaths were associated with falls, two were associated with an air embolism, two with the death of a neonate, one with suicide/attempted suicide, one with a maternal death, and one with a medication error.
“Behind each of these events is a patient and family,” said Dr. Rahul Koranne, chief medical officer of the Minnesota Hospital Association. “Minnesota's nation-leading adverse health events reporting system provides a strong framework for learning and continuous quality improvement - and our hospitals, health systems and care teams use what they learn to continually improve patient safety.”
The year also included an increase in wrong site surgical or invasive procedure events. There were 55 cases involving wrong surgeries, wrong-site surgeries, and left or retained objects. Though on the rise, these events remain rare, as there were 3.1 million surgeries and invasive procedures during the year. The most common types of surgeries/invasive procedures involved in these events were spinal injections/procedures and pre-procedural injections such as pain blocks. In a significant percentage of these cases, an effective “Time Out” and verification of the surgical site was not done.
While the number of events increased overall, there were areas of improvement such as the number of pressure ulcers declined to 120. As part of the reporting system, MDH, the Minnesota Hospital Association (MHA) and Stratis Health implemented a number of actions in 2017 including additional trainings and safety alerts related to medication errors involving Epinephrine and pressure ulcers. MHA hosted a medication safety conference on controlled substance diversion, culture of safety and medication reconciliation.