Number of Adverse Health Events in Minnesota Hospitals Increases Slightly in 2011

Total events increased from 305 in 2010 to 316 in 2011; however, overall harm is down.

The number of reportable adverse events in Minnesota hospitals, ambulatory surgical centers, and community behavioral health hospitals increased from 305 in 2010 to 316 in 2011, according to a report released by the Minnesota Department of Health (MDH). Despite the increase, the number of events resulting in serious injury or death to a patient decreased from 107 in 2010 to 89 in 2011. This is the lowest level of harm since 2007.?? The eighth annual adverse health events report summarizes the number and types of events that occurred between October 7, 2010, and October 6, 2011, in the roughly 200 facilities covered by the adverse health events reporting law. The 316 events were reported by 61 hospitals and seven surgical centers. ??Nearly all of the increase can be attributed to increases in two categories: pressure ulcers and wrong procedures. The number of pressure ulcers rose to 141, an increase of 19 percent, while reports of wrong procedures increased by 63 percent, to 26. If the number of events in those two categories had been at the same level as the previous year, total reported events would have been lower than in 2010. The higher number of reports in these two categories masks an overall reduction in harm and significant improvements in three areas where Minnesota has implemented strong, statewide efforts: falls, retained objects in labor and delivery, and wrong site surgeries/invasive procedures. Successes in 2011 include:

The number of serious falls was 71, a decrease of 11 percent from 2010 and a decrease of more than 25 percent from a high of 95 serious falls three years ago. Only the most serious falls are required to be reported through this system; therefore, every prevented fall means serious harm or death to a patient has been avoided.

After increasing for the last few years, wrong site surgeries/invasive procedures declined by 23 percent in 2011 (from 31 to 24).

After two years of sustained work by staff in labor and delivery units to implement processes for counting sponges and other items, no retained foreign objects were reported in labor and delivery in 2011.

“Even though some of our long-term patient-safety efforts are paying off, we must never lose sight of the fact that each adverse event has an impact on a patient and that patient’s family,” said Dr. Ed Ehlinger, Minnesota Commissioner of Health. “We need to continue working hard to eliminate barriers to improving patient safety, especially in the areas of pressure ulcers and wrong procedures.”

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. ??”One of the most crucial things we have learned from the adverse health event reporting system over the last eight years is that just telling staff to ‘remember to do the right thing’ is not enough,” said Diane Rydrych, director of MDH Health Policy Division. “To truly change practice, providers need to adopt solutions involving modifications in workflow or workspaces, staff roles, technology, team dynamics and organizational culture. But to do this successfully, leadership needs to be fully engaged,” Rydrych said. ?

According to Rydrych, one promising new avenue for strengthening this work is the Minnesota Alliance for Patient Safety’s (MAPS) Roadmap to a Safe Culture, which will begin in early 2012. The campaign will provide health care leaders in hospitals, clinics, surgical centers and long-term care facilities with proven strategies for measuring and improving safety, increasing accountability for all providers, creating a learning and patient-centered environment, and imbedding continuous process improvement at all levels of the organization. ?

“The Roadmap to a Safe Culture will offer standardized best practices and strategies for improving safety culture across the care continuum,” said Nancy Kielhofner, executive director of MAPS. “This is the kind of national leadership that will take the culture of patient safety to the next level in health care organizations.”??

The legislation creating the adverse health events reporting system was championed 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. ??In 2010, Minnesota hospitals reported roughly 2.6 million patient days and more than 10 million outpatient registrations. Ambulatory surgical centers reported more than 216,000 registrations for same-day surgeries. ??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/.