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Friday, February 26, 2016

Health department report shows progress in prevention of adverse health care events

The Minnesota Department of Health released its 12th annual Adverse Health Events report Friday as part of its nation-leading hospital and ambulatory surgical center safety program.

In 2015, hospitals made progress on reducing two stubborn areas of adverse events: falls and surgical errors related to not removing all the materials involved in surgeries. During the October 2014 to October 2015 reporting period, there were 67 cases of falls associated with serious injury or death. That total was the lowest ever reported to the system.

Overall, serious injuries and deaths were similar to last year's report. Minnesota hospitals and surgical centers reported 316 adverse health events, including 93 serious injuries and 16 deaths. This was similar to the previous year's 98 serious injuries and 13 deaths.

Hospitals and surgical centers reported 22 cases of retained foreign objects after surgery, as opposed to 33 in the previous year. This continues a downward trend following years of intense focus by hospitals and surgical centers to train staff and implement procedures to account for all objects before the end of a surgery.

"Although even one avoidable death or injury is too many, this year's report shows the progress we are making - especially in preventing falls," said Minnesota Health Commissioner Dr. Ed Ehlinger. "Our approach of openness and public reporting is helping to encourage overall improvements and new opportunities to protect patients."

The most frequently reported events were pressure ulcers (104) and falls associated with serious injury or death (67). The next most frequently reported events were surgeries/invasive procedures performed on the wrong site/body part (29). This year saw an increase in procedures done at the wrong spine level.

The goal of the adverse reporting system is to use data to identify and implement best practices that improve patient safety. A total of 30 states track adverse events but Minnesota is one of only five states to publicly report events at a facility level.

"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."

As a direct result of this system, MDH and its partners took a number of steps in 2015 to prevent adverse events. MDH issued a safety alert to hospitals urging them to review discharge

processes to ensure providers were reviewing test results or the follow-up plan for on pending results with patients. MDH and MHA convened an expert group to develop best practices for test result communication.

In 2016, expected patient safety improvements include working with surgery teams to address full and accurate completion of the Minnesota Time Out process for every patient, every time and working to improve specimen collection and transport to prevent biological specimen loss or damage.

The full report is available at Adverse Health Events Reports and Fact Sheets.

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