<p> MN ALLIANCE FOR PATIENT SAFETY/MDH Fall Event Summary October 8, 2013</p><p>Attendees: Roughly 90 attended the conference held at the Wilder Foundation facility in St. Paul. </p><p>Presenters: The group was welcomed by Diane Rydrych (MDH) and Marie Dotseth (MN Alliance for Patient Safety). Collaborative efforts to build a new reporting system began 10 years ago following the IOM report “To Error is Human”. Both the report and the reporting system for Adverse Health Events (AHE) developed were considered ground breaking due to the transparency and learning collaboration.</p><p>Facilitated discussions occurred for all attendees asking what would serve as incentives for reporting events. Much discussion revolved around Just Culture.</p><p>Rachel Jokela from MDH reviewed the AHE reporting tool, goals and findings:</p><p>AHE Report Categories • Focus on highest frequency and risk • Prevention and patient populations • Need comparable or baseline data Future AHE Reporting Goals • Include all health care facilities • A tiered reporting system • Accessible, interactive training Most valuable part of AHE program • Training/Education • Resources • Staff awareness of patient safety • Case studies • Public accountability • Learning from events • Transparency Survey Analysis Findings: How can we help in the upcoming year? • Get Providers on board • Continued learning/sharing sessions around the top problem areas. • Have a physician that can be available to come out and talk with our Medical Staff • Provide more programs through video-conferencing • Site visit to facilities and offer suggestions for improvement • Offering more collaborative learning opportunities/sharing around the highest AHE categories, with national expert speakers.</p><p>Stakeholder Panel Discussion-“Thoughts for the future” Facilitator – Jennifer Lundblad, President & CEO, Stratis Health Panelists- Lorry Massa, Minnesota Hospital Association Doug Beardsley, Care Providers of Minnesota, Inc. Darrell Shreve, Aging Services of Minnesota Shirley Brekken, Minnesota Board of Nursing Ruth Martinez, Minnesota Board of Medicine Nancy Page, Minnesota Ambulatory Surgery Center Association Ellen Benavides, Minnesota Department of Health</p>