Minnesota Patient Safety Report Raises Concerns

Minnesota's hospitals and ASCs reported the same number of adverse events last year as in the previous one, but more patients injured or dead as a result of those incidents, says a recently published state report.

According to the Minnesota Department of Health's ninth annual public accounting of adverse health events, the state's surgical facilities reported 314 adverse events between October 2011 and October 2012 (unchanged from the previous 12 months), with 14 patient deaths (up from 5) and 89 serious injuries (up from 83).

Of particular note: almost 90% of the patient injuries or deaths resulted from falls. The 79 reported falls, which resulted in 6 deaths, were not as high as 2008's 95 falls with 10 deaths (the first year that fall injuries were counted alongside fall deaths), but an increase over 2011's 71 falls with 3 deaths.

"This year's report shows that as a state we really need to redouble our efforts to reduce falls in hospitals," says Edward Ehlinger, MD, MSPH, Minnesota's commissioner of health. "While falls in health care settings can be very difficult to prevent, we also need to look at all opportunities to prevent injury when falls do occur, by focusing interventions on each patient's specific risk factors."

In about 60 percent of the falls, the report explained, the patient had been tended to by clinical personnel within the previous 30 minutes, then attempted to climb out of bed themselves.

In addition to falls, the state also saw increases in wrong-site surgeries and patient suicides or escapes. The report noted, however, that medication errors fell 75% to their lowest ever recorded level; retained objects dropped 16%, their first decline in 5 years; and pressure injuries decreased 8% from last year's high.

Minnesota was the first state to require surgical facilities to track 28 types of adverse events for public reporting and analyze the reasons they occurred.

David Bernard