Minnesota Department of Health Publishes First-Ever Report on Adverse Events in Hospitals

MINNEAPOLIS -- The Minnesota Department of Health (MDH) today released the first-ever report on preventable adverse events in Minnesota hospitals. These events include errors that hospitals should always strive to prevent, such as wrong-site surgery, death from medication error, and serious disability from falls.


The legislation creating the adverse health event reporting system and calling for public reporting was championed by Minnesota hospitals and was signed into law in 2003. The Minnesota Hospital Association (MHA) and MDH have been working closely together to implement the new law.


This report is an important step in improving patient safety for every Minnesotan, said Governor Tim Pawlenty. Weve never had a report that measured this before and if you dont measure something, you cant improve it. Now we have a way to consistently measure, report and have accountability for events that we all agree should never happen.


The law requires all Minnesota hospitals to report to MDH whenever any of 27 so-called never events occurs. The National Quality Forum, a Washington, D.C.-based health care standards-setting organization, created this consensus-based list of adverse events in 2002 at the request of the federal government, after an Institute of Medicine report estimated that medical errors in hospitals cause 44,000 to 98,000 deaths every year in the U.S.


Kenneth W. Kizer, MD, MPH, president and CEO of NQF, applauded Minnesota for being the first state to follow NQFs recommendations for reporting adverse events. Publication of this document demonstrates that Minnesota is in the vanguard of public reporting of medical errors, Kizer said. With the new law and its clearly defined list of adverse health care events, Minnesotas state government is now able to provide more effective oversight and to make health care safer.


The report summarizes the number and type of events that occurred in Minnesota hospitals during the start-up period of the law, between July 2003 and October 2004. According to the report, during that period, 99 adverse events were reported by 30 hospitals; and 20 deaths and four serious disabilities resulted from the events.


Although one medical error is too many, Minnesotans should take comfort in knowing that hospital officials and health care experts have been working diligently to prevent errors, Minnesota Comissioner of Health Dianne Mandernach said. This report gives us the kind of information we can use to better focus our overall efforts at improving patient safety.


In addition to reporting individual events, hospitals are required to report on the underlying cause of each event and the corrective actions being taken to prevent similar errors in the future. This law provides a forum to share the reported information with hospitals across the state so they can learn from one another.


The report notes that the most frequently reported adverse event was a foreign object left in a patient after surgery; the next most frequently reported event was stage three or four pressure ulcer. Almost a third of the wrong body part surgery reports occurred during spine surgeries (spinal surgeries are especially challenging because of the complexity of the spine).


Minnesotas hospitals are already implementing a variety of proven strategies for preventing many types of errors. Such strategies include developing new ways to track objects used in surgical procedures, improving how patients are assessed for the risk of falling, regularly re-positioning patients at risk of pressure sores, and adding special labels to high-risk medications.


While this reporting system has already lead to improvements, hospitals understand that these events can be devastating for patients, their families and the caregivers involved, said Bruce Rueben, president of the Minnesota Hospital Association. Thats why Minnesota hospitals worked so hard to get the law passed and implemented.


Mandernach suggested that consumers should use the information in the report to become more involved in their health care. Consumers should use this report to help identify situations of interest to them and then ask their healthcare providers what theyre doing to provide the safest care possible, Mandernach said.


Mandernach added that it is difficult to compare hospitals using just the numbers in the report. The errors documented in this report represent a very small fraction of all the procedures and admissions in Minnesota hospitals, Mandernach said. She also pointed out that the number of events reported by hospitals can be influenced by a number of factors, including the size of the hospital, staff awareness of and dedication to reporting, and different interpretations of what should be reported.


Minnesota hospitals admit nearly 600,000 patients per year, with an average length of stay of more than four days. In addition, in one year, Minnesota hospitals see 1.5 million patient visits in their emergency departments; 300,000 same-day surgery cases are treated, and there are more than 5.5 million visits for a variety of other hospital-based treatments or procedures, from kidney dialysis to follow-up X-rays.


Source: Minnesota Department of Health