Adverse Health Event Reporting in Minnesota a Valuable Tool

By John Tingle

doctors performing surgery
Medical errors are a common cause of death globally. (thinkpanama/flickr)

“Medical errors are the third leading cause of death in the United States,” says a new report by the World Health Organization. And in the United Kingdom, “recent estimations show that on average, one incident of patient harm is reported every 35 seconds.”

Patient safety remains an issue of concern for all countries across the globe. But by observing what other countries do and report about patient safety we can avoid the costly mistake of trying to reinvent the wheel when information is already available about important trends.

The Minnesota Department of Health (MDH) have recently published their 14th Annual Public Report on Adverse Health Events in Minnesota. The report contains a lot of detailed patient safety information, analysis, and trends which will be of use to health carers and patient safety policy developers everywhere.

In 2003 Minnesota became the first state in the US to establish a mandatory adverse health care events reporting system that tracks events such as wrong-site surgery, for example. The legislation covers Minnesota hospitals, free standing outpatient surgical centers, and regional treatment centers. These facilities are required by law to disclose when any of 29 serious reportable events occur.

The Report

The report, shows that between October 7, 2016, and October 6, 2017, 341 adverse health events were reported to the MDH. There was an increase in fall related deaths and wrong site surgical /invasive procedure events, and a decrease in pressure ulcer reports.

There were 12 deaths and 103 serious injuries reported. The report states that over the life of the reporting system in Minnesota, falls, medication errors, and product or device malfunction have been the most common cause of serious patient injury or death.

As in previous years, falls and pressure ulcers were the most commonly reported types of events, accounting for 59 percent, followed by surgical, invasive procedures at 24 percent (83 events). There were 36 cases of wrong site surgeries, invasive procedures reported and 27 cases of retained foreign objects (RFO) after surgeries or invasive procedures. The majority of these (59 percent) occurred in an operating theatre, either as an in or out patient.Nearly half, or 48 percent of the RFOs were described as “soft goods,” such as sponges and other soft pads.

Pressure ulcers have been the most commonly reported adverse health event since the reporting system first began in 2003. Pressure ulcers often represent roughly a third of reported events. The top pressure ulcer sites were in the area of the coccyx, sacrum (40 per cent), face, ear (12 per cent) and buttocks (6 per cent).

In terms of clinical unit location where these events occurred, the majority occurred in the ICU (Intensive Care Unit) (53 percent), and 29 percent occurred in adult medical surgical units.

The report states that there were 77 reported falls that resulted in serious injury to a patient as well as 5 fatal falls. This is the second year of an increase in the number of falls reported.

The report provides an excellent real-time view of some major patient safety issues in a very clear and concise way, and the Minnesota reporting model has global value in terms of patient safety policy development and practice. 

John Tingle

John Tingle

John Tingle is a regular contributor to the Bill of Health blog. I am a Lecturer in Law, Birmingham Law School, University of Birmingham, UK; and a Visiting Professor of Law, Loyola University Chicago, School of Law. I was a Visiting Scholar at Harvard Law School in November 2018 and formerly Associate Professor at Nottingham Law School, Nottingham Trent University in the UK. I have a fortnightly magazine column in the British Journal of Nursing where I focus on patient safety and the legal aspects of nursing and medicine. I have published over 500 articles and a number of leading texts in patient safety and nursing law. My current research interests are in global patient safety, policy and practice, particularly in African health care systems. My most recent publication is: "Global Patient-Safety Law Policy and Practice," edited by John Tingle, Clayton O'Neill, and Morgan Shimwell, Routledge 2018.

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