Preventable hospital errors show increased reporting in Minnesota

St. Cloud, MN – New serious preventable hospital errors reporting shows past mistakes buried, rather than reported.

As a hospital patient are you safe? Are you safer this year than last year? Until everyone gets on board with reporting preventable errors the answers to those two questions can’t be taken seriously.  Of the 18 preventable events, which are you likely to encounter on your way to better health? It’s refreshing to see hospitals begin to tackle in an open way, these issues. They can dislike the legal tort system all they wish but until they begin to openly manage preventable errors the public will not tolerate institutional ignorance.

Minnesota’s new reporting requirements for serious preventable hospital errors resulted in an almost three-fold increase in the number of reported errors from the previous year.

The number of adverse events in Minnesota hospitals, ambulatory surgical centers and community behavioral health hospitals increased from 125 to 312 in 2008. In the absence of the new reporting requirements, the number of reported adverse events would have been 141.

In addition to the seven falls and four ulcers included in this year’s report, St. Cloud Hospital had seven “adverse health events” — one more than last year’s, which predated reporting requirements approved during the 2007 legislative session.

None of the 18 adverse health events reported this year by St. Cloud Hospital resulted in death, according to the statewide report released today by the Minnesota Department of Health.

If you’re from Minnesota you may wish to read this or other articles about this subject and order the 2008 or the 2007 report.  You should put this report in perspective, more reports doesn’t mean more mistakes; assuming in previous years they were underreported.

“Preventable adverse events include such things as pressure ulcers, retained objects after surgery, wrong-site surgeries, wrong procedures, death or serious disability from a medication error, and death from a fall. The most frequent events noted in this year’s report were stage three or four pressure ulcers (43), wrong site surgery (24), and a foreign object left in a patient after surgery (25).”

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 http://www.mnhospitals.org.

John Stieger
MDH Communications
(651) 201-4998

As a patient you can search by facility and cross-reference with preventable errors. Be safe, be smart and be proactive in protecting yourself.

Patient Safety

As part of its mission to protect, maintain, and improve the health of all Minnesotans, the Department of Health is a leader in promoting patient safety and the prevention of adverse health events. MDH is a partner in the Minnesota Alliance for Patient Safety, a broad-based partnership established by MDH, the Minnesota Hospital Association, and the Minnesota Medical Association and since joined by over 50 stakeholder groups.

MDH also administers the Adverse Health Care Events Reporting System. This reporting system, established in 2003, requires all Minnesota hospitals, ambulatory surgical centers, and community behavioral health hospitals to report whenever one of 28 "never events" occurs. Reportable events include surgery on the wrong patient or body part, objects retained in a patient’s body after surgery, death associated with a fall, and death or serious disability from a medication error.

By supporting learning and accountability, this system is helping to improve patient safety across the state, and serves as a model for other states interested in developing mandatory public reporting systems.

Search facilities' adverse events reporting
Searchable database that displays reports about individual hospitals.

Information for consumers, patients and families
Factsheets and links specifically for consumers and patients.

Adverse events reporting system
List of 28 reportable events, links to statute, background sheets and articles.

Wrong-site surgery
Minnesota research and recommendations related to prevention of wrong site surgery, retained objects, and other surgical events.

Patient safety publications
Current and previous reports on patient safety.

Patient safety links
Links to other sites with safety and quality information.

Patient safety training
Past and upcoming training.

For more information about this page, please contact the MDH Division of Health Policy at 651-201-3564.

In Des Moines, Iowa contact Steve Lombardi. In St. Cloud, Minnesota contact Attorney Mike Bryant and in Hawaii, Wayne Parsons.