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Error Reporting Works

10-year safety review in Minnesota shows adverse events are on the decline.

Published: January 24, 2014

It's been a decade since the Minnesota Department of Health began requiring the state's hospitals and surgery centers to report serious but preventable medical errors such as wrong-site surgery, retained objects, medication errors and patient falls. A 10-year review of the reporting program shows it appears to be working.

The MDH says incidences of wrong-site surgery and reatined objects decreased from 89 in 2011 to 61 in 2013.

Overall, says the MDH, patient harm from adverse events is trending downward. Last year, 258 total errors were reported, down 18% from 2012, which is the program's largest year-to-year drop and the first time since 2007 — when changes broadened the reporting criteria of reportable offenses — that the total number of errors didn't reach 300. Facilities are also better at identifying and addressing medical errors. In 2003, it took more than 60 days to discover adverse events. In 2013, errors were typically recognized in just 10 days.

The health department's recent survey of staff and administrators at hospitals and surgery centers revealed most believe their facilities are generally safer than a decade ago: Nearly 70% of respondents currently rate patient safety as "very high" compared with the 33% in 2003 who believed protecting patients was a priority.

But the 15 adverse-event-related patient deaths reported last year tempered the MDH's rosy outlook. Ten of the mortalities were the result of falls, which the MDH calls one of the most difficult hazards to eliminate.

"Overall, the 10-year look back shows encouraging progress," says Diane Rydrych, director of MDH's health policy division. "But the fact that harm did not decrease in 2013 shows that this is also the sort of work that is never done and requires constant attention."

Daniel Cook


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