The number of adverse events in Minnesota hospitals, ambulatory surgical centers and community behavioral health hospitals increased from 301 in 2009 to 305 in 2010, according to a report released today by the Minnesota Department of Health (MDH). The seventh annual adverse health events report summarizes the number and types of events that occurred between October 7, 2009, and October 6, 2010, in the roughly 200 facilities covered by the adverse health events reporting law. The 305 events were reported by 60 hospitals and two surgical centers.
The overall profile of events was similar to previous years, with falls, pressure ulcers and retained foreign objects making up the majority of events. Other results include:
• Ten deaths and 97 serious injuries resulted from the reported events.
• Last year's 20 percent reduction in falls associated with serious injury or death was largely maintained. A total of 80 falls were reported, up from 76 in the previous year but down from a high of 95 two years ago.
• The number of serious bedsores remained roughly constant, decreasing from 122 to 118.
• The number of events related to surgery or invasive procedures remained unchanged at 83.
"While these events are still exceedingly rare, we must never lose sight of the fact that each adverse event has an impact on a patient and their family, and that most are preventable," said Diane Rydrych, assistant director, MDH Health Policy Division. "Because of the multiple challenges facing hospitals today, we're concerned that many health care leaders may not be fully engaged in making changes that will prevent harm to patients. That's why we are stepping up our call to action to health care leaders to strengthen their commitment to make patient safety their highest priority."
Dr. James Reinertsen, a national patient safety expert, agrees that more adverse events could be prevented if hospital boards took stronger steps to adopt strong patient safety practices. "Minnesota is doing great things to reduce adverse events, but we know that efforts often fall short because hospitals lack the will to insist on rigorous application of patient safety methods," Reinertsen said. Among other things, he encourages hospitals to publicize safety goals and performance. "When hospitals share reports with the public, their performance tends to improve, especially for those results that don't look so good." Reinertsen heads The Reinertsen Group, a national health care quality improvement organization. He was formerly the chair of the Institute for Clinical Systems Improvement and CEO of Park-Nicollet. Last week, he received the 2011 Eisenberg Award for patient safety from the National Quality Forum and The Joint Commission.
Reinertsen and Rydrych said that boards of directors and CEOs should send a strong message that commitment to safe practices is non-negotiable for all providers all the time. They noted that leaders can keep the focus on eliminating preventable harm by using strategies such as:
• Telling patient stories of preventable harm at every board meeting.
• Training board members on patient safety.
• Requiring board members to participate in "leadership rounds" or other activities that put them in contact with front-line staff and patients.
• Ensuring that policies and protocols reflect best practices and community standards for safety, and include a hard-stop policy for when best practices are not being followed.
• Showing board members the personal impact of each instance of preventable harm in their facility, rather than focusing just on rates and benchmarks.
• Holding physicians and other providers accountable for compliance with all best practices to prevent harm and for full engagement in safety efforts.
"While we know we can do more to prevent adverse events, it is important to point out that we are learning some valuable lessons every year through our reporting system," said Rydrych. "Learning about why events happen, then working to prevent them from happening again, is the best way to improve patient safety."
Rydrych noted the following key lessons learned in 2010:
• In response to the finding that more than 25 percent of reported pressure ulcers are associated with the use of a device such as a cervical collar, tube or splint, a Minnesota Hospital Association (MHA) pressure ulcer advisory committee developed recommendations for preventing pressure ulcers associated with those devices.
• As a result of data showing that the surgical site mark was not located and verbally confirmed during the time-out process in more than a third of wrong-site surgery cases, MDH and MHA issued a safety alert reminding facilities of the importance of this step and providing guidance on how to implement it.
• Based on the finding that a number of falls involved patients who had previously reliably called for assistance with toileting, a falls advisory group is exploring ways to account for changes in patient behavior related to asking for help. Examples include providing additional education to patients when they are feeling better to remind them of the importance of calling for help, or earlier assessment and interventions for increased confusion.
In the coming year, MDH and its partners will continue to focus on identifying and sharing information about risks and successful strategies for preventing serious events and promoting a statewide culture of safety.
The legislation creating the adverse health events reporting system was championed by Minnesota hospitals and signed into law in 2003. The law requires all Minnesota hospitals and ambulatory surgical centers to report to MDH whenever any of 28 serious events occurs. The National Quality Forum, a Washington, D.C.-based health care standards-setting organization, created this list of adverse events in 2002 following an Institute of Medicine report estimating that medical errors in hospitals cause 44,000 to 98,000 deaths every year in the United States.
In 2009, Minnesota hospitals reported more than 2.6 million patient days and nearly 10 million outpatient registrations. Ambulatory surgical centers reported more than 212,000 registrations for same-day surgeries.
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. More information about hospitals can be found at www.mnhospitals.org.