2007 Minnesota Department of Health
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ADVERSE HEALTH EVENTS IN MINNESOTA THIRD ANNUAL PUBLIC REPORT | JANUARY 2007 MINNESOTA DEPARTMENT OF HEALTH ADVERSE HEALTH EVENTS IN MINNESOTA THIRD ANNUAL PUBLIC REPORT | JANUARY 2007 ADVERSE HEALTH EVENTS IN MINNESOTA 2007 PUBLIC REPORT TABLE OF CONTENTS Introduction ...................................................... 4 How to use this report ............................................ 6 Highlights of 2006 Activities ...................................... 7 Overview of Reported Events ..................................... 9 Root Cause Analysis Findings .................................... 10 Preventing Future Events ........................................ 12 Categories of Reportable Events ................................. 19 Events Reported Between October 7, 2005 and October 6, 2006 ................................................ 20 Reported Events by Facility ...................................... 25 Appendices Appendix A: Background on Minnesota’s Adverse Health Events Reporting Law ...................... 74 Appendix B: Reportable Events as Defined in the Law ........ 75 Appendix C: Links and Other Resources ...................... 77 This report can be found on the internet at: www.health.state.mn.us/patientsafety For More Information Contact: Division of Health Policy Minnesota Department of Health 651-201-3550 MINNESOTA DEPARTMENT OF HEALTH INTRODUCTION Since 2003, Minnesota hospitals, ambulatory surgical investigation of events and develop stronger corrective centers, and regional treatment centers have been actions. required to report whenever one of 27 serious events 4 Death records from all Minnesota counties are takes place. These events include falls that are associated reviewed monthly to ensure that all reportable events with a death, foreign objects left in the body after surgery resulting in death are reported into the adverse health or other invasive procedures, and surgery or other events reporting system. invasive procedure on the wrong person or body part. Between October 7th, 2005 and October 6th, 2006, 154 4 MHA is issuing “calls to action” to hospital CEO’s, asking events were reported to the Minnesota Department of them to fully implement best practice techniques Health (MDH). This report provides information about to prevent falls, retained objects, pressure ulcers and where these events happened, why they happened, and surgery on the wrong body part. what’s being done to prevent them from happening 4 MDH and MHA have worked with consumer groups again, and provides important information about quality around the state to make this information easier to and safety to help consumers make wise choices about understand, so that patients and family members can their care. ask more knowledgeable questions about their care and understand the important role they play in patient The most important aspect of the reporting system is not safety. the numbers themselves, but rather what is being learned 4 A new consumer guide to adverse events is now from them. Counting events will not, by itself, make the available at www.health.state.mn.us/patientsafety, and system safer. But finding out why events happen, and the adverse health events website has been modified then working to prevent them from happening again, to support a searchable database of adverse events by will lead to changes that increase safety for all patients. facility. The reporting system is designed to foster both inquiry and evidence-based intervention. Every facility that 4 Key learnings continue to be shared with facilities experiences one of these events is required to conduct through newsletters, safety alerts, meetings, summits, an in-depth analysis of why it occurred, and every event collaborative groups, and other avenues. is reviewed by a team of clinical experts. Facilities are required to implement system changes to prevent similar Despite Minnesota’s pioneering work to date to ensure events from happening again, and key learnings are the highest level of patient safety, adverse health events shared so that all facilities benefit, whether or not they’ve remain a serious issue here and across the country. experienced an event. Every reported event, regardless of the level of harm to the patient, represents a situation that should not have Minnesota leads the nation in its efforts to improve happened. The factors that lead to these events are patient safety. The Minnesota Alliance for Patient complex and often system-wide, making simple solutions Safety, a broad-based partnership including MDH, the or quick fixes unlikely to succeed. Reducing the number Minnesota Hospital Association (MHA), the Minnesota of events will take support at all levels of hospital, surgical Medical Association, and more than 50 other stakeholder center, and regional treatment center administration, groups, recently earned the 2006 John M. Eisenberg as well as by staff, patients, family members, and other Patient Safety and Quality Award for its work in creating stakeholders. It will be neither an easy nor a quick a more transparent and accountable health care system process, but it is a process to which stakeholders around and its efforts to reduce adverse events. Minnesota the state are committed. hospitals also received top marks for patient safety in 2006 from HealthGrades, a national health care research company. Continuing this work, MDH, along with MHA, has spent the last year working to make sure that the adverse events reporting system contains high-quality information that is shared as widely as possible: 4 Staff from more than 75 facilities attended regional training sessions designed to help them improve their ADVERSE HEALTH EVENTS IN MINNESOTA 2007 PUBLIC REPORT Reported Adverse Health Events by Category October 7, 2005 – October 6, 2006 Other events Criminal events 10 4 Retained objects Falls 42 12 Medication events 6 Wrong site surgery 23 Pressure ulcers/ bedsores Other surgical 48 events 9 For more information about the adverse health events reporting system, visit www.health.state.mn.us/patientsafety. MINNESOTA DEPARTMENT OF HEALTH HOW TO USE THIS REPORT This report is one of many sources of information now available on health care quality and patient safety in Minnesota. It is designed to help patients identify safety Sources OF QUALitY And PAtient SAFetY issues to discuss with their care providers, and to give INForMAtion policymakers an overview of patient safety activities and issues in the state. But it is only one piece of the larger Minnesota Department of Health picture of patient safety and quality. Other good sources www.health.state.mn.us/patientsafety of information on health care quality are listed at right Includes a consumer guide to adverse events, searchable and in Appendix C. database of adverse events by facility, fact sheets about different types of events, FAQs, and links to other sources The fact that health care providers are looking for of information. potentially dangerous situations and reporting them in order to learn and prevent harm to patients is a major Minnesota Health Information step forward in patient safety. Rather than using this www.minnesotahealthinfo.org report to compare facilities based on incidence rates or to Links to several sites comparing cost and quality at compare data from multiple years for a facility, consumers hospitals, physician and medical groups, and other should use this report to identify situations of interest to facilities. them and then ask providers what is being done in their facility to prevent this type of event from occurring. Healthcare Facts www.healthcarefacts.org It is important to be aware that events listed in this report Comparative information about quality at Minnesota represent a very small fraction of all of the procedures hospitals and primary care clinics. and admissions at Minnesota hospitals, regional treatment centers and ambulatory surgical centers. The Leapfrog Group Patient awareness is a very important tool to improve www.leapfroggroup.org safety, but it is also important to keep these numbers in Hospital safety and quality ratings based on multiple perspective. factors. The number of reported events might be higher or lower Minnesota Hospital Quality Report at a specific facility for a variety of reasons. A higher www.mnhospitalquality.org number of reported events does not necessarily mean Searchable database of hospital performance on best that a facility is less safe. Facilities vary not only by size practice indicators related to heart attack, heart failure, but also in the number and type of procedures that are and pneumonia. conducted each year and in the type of patients seen; this can lead to fluctuations in the number of events MN Community Measurement (www.mnhealthcare. reported. In some cases, the number of events may org) provides comparative information about provider be higher at facilities that are especially vigilant about groups and clinics including best practices for diabetes, identifying and reporting errors. The reporting system asthma, and other conditions, as well as who does the itself may also have an effect, by fostering a culture in best job providing that care. which staff at all levels feel more comfortable reporting potentially unsafe situations without fear of reprisal. It is important to note that in these cases, higher numbers may represent a positive trend towards greater attention to adverse events, their cause and prevention. ADVERSE HEALTH EVENTS IN MINNESOTA 2007 PUBLIC REPORT HIGHLIGHTS OF 2006 ACTIVITIES