January 17, 2008 – The Minnesota Department of Health (MDH) has put out its fourth annual report on preventable adverse health events in Minnesota hospitals, ambulatory surgical centers and regional treatment centers. The report summarizes the number and types of events that occurred between October 7, 2006, and October 6, 2007, in the 197 facilities covered by the adverse health events law. During that period, 125 adverse events were reported by 38 hospitals and four surgical centers, and 13 deaths and 10 serious disabilities resulted from the events.

Preventable adverse events include such things as pressure ulcers, retained objects after surgery, wrong-site surgeries, wrong procedures, death or serious disability from a medication error, and death from a fall. The most frequent events noted in this year’s report were stage three or four pressure ulcers (43), wrong site surgery (24), and a foreign object left in a patient after surgery (25).

“We must never lose sight of the fact that every adverse event had an impact on a patient and their family,” said Minnesota Commissioner of Health Dr. Sanne Magnan. “Our reporting system, however, is revealing important results. Minnesota hospitals and surgical centers continue to develop and improve strategies to identify, analyze and prevent adverse events. The knowledge gained from this process is helping to improve the overall safety of care in Minnesota.”

In addition to reporting individual events, facilities are required to report on the underlying causes of each event and the corrective actions being taken to prevent similar events from happening in the future. This reporting system provides a forum for sharing key findings with hospitals and surgical centers across the state so they can learn from one another. Generalized information from the adverse health events reporting system is also shared with facilities through newsletters highlighting best practices, safety alerts and presentations throughout the year.

Minnesota hospitals, ambulatory surgical centers and regional treatment centers to report to MDH whenever any of 27 events occurred. The National Quality Forum, a Washington, D.C.-based health care standards-setting organization, created this list of adverse events in 2002 at the request of the federal government. This followed an Institute of Medicine report estimating that medical errors in hospitals cause 44,000 to 98,000 deaths every year in the United States. During the 2007 legislative session, the reporting law was modified to add a 28th event and to broaden the definition of other reportable events; these changes will be reflected in the 2009 report.

Diane Rydrych, assistant director of the MDH Division of Health Policy, said that consumers should use the information in the report to become more involved in their health care. “There are a growing number of tools that will help consumers become more involved in their health care,” Rydrych said. “By reviewing the information in the adverse health events report, consumers can have better conversations with their providers about steps they are taking to ensure safe, high-quality care.” Rydrych noted that a consumer guide to adverse health events is available on the MDH Web site.

Commissioner Magnan added that it is difficult to compare facilities using the numbers in the report because the reported errors are a small fraction of all the procedures and admissions in Minnesota hospitals and surgery centers. “Focusing only on the numbers doesn’t tell the whole story,” Magnan said. “What’s more important are the new insights we’re gaining on how errors happen and how they can be prevented.”

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.

Labels: adverse health events, mediction error, Minnesota Department of Health, retained object, wrong site surgery