Minnesota Department Report On Adverse Events In Minnesota Hospitals

The Minnesota Department of Health (MDH) released its second annual report on preventable adverse events in Minnesota hospitals. This year’s report also includes adverse events that occurred in ambulatory surgical centers. Preventable adverse events include such things as wrong-site surgeries, pressure ulcers, retained objects after surgery, death or serious disability from a medication error, and death from a fall.

The report summarizes the number and types of events that occurred in Minnesota hospitals and surgical centers between October 7, 2004 and October 6, 2005. According to the report, during that period, 106 adverse events were reported by 47 facilities, and 12 deaths and nine serious disabilities resulted from the events.

“Our adverse health events reporting system provides us with a wealth of information that health care facilities can use to improve patient care,” said Minnesota Commissioner of Health Dianne Mandernach. “As a result of last year’s report, we were able to identify areas of concern and begin addressing them through several statewide patient safety initiatives. With this year’s report, we will have even more information to help us develop strategies for preventing adverse events.”

The report notes that the most frequently reported event was a stage three or four pressure ulcer (serious bed sores); the next most frequently reported event was a foreign object left in a patient after surgery. Roughly half of the “wrong body part surgery” reports occurred during surgeries involving the knees or chest.