Minnesota Adverse Health Events 2017

106 Pages·2017·1.26 MB·English

ADVERSE HEALTH EVENTS
IN MINNESOTA
14TH ANNUAL PUBLIC REPORT | FEBRUARY 2018
EMBARGOED UNTIL 12:01 A.M.
THURSDAY, FEBRUARY 22
Please do not publish or broadcast stories until 12:01 a.m.,
Thursday, February 22, 2018
Adverse Health Events in Minnesota
Annual Report | February 2018
Minnesota Department of Health
Division of Health Policy
P.O. Box 64882
Saint Paul, MN 55101
651-201-5807
www.health.state.mn.us/patientsafety
As requested by Minnesota Statute 3.197: This report cost approximately $8,200 to prepare,
including staff time, printing and mailing expenses.
Upon request, this material will be made available in an alternative format such as large print,
Braille or audio recording. Printed on recycled paper.
CONTENTS
EXECUTIVE SUMMARY .......................................................................................................................... 1
HIGHLIGHTS OF 2017 ACTIVITIES .......................................................................................................... 3
OVERVIEW OF REPORTED EVENTS & FINDINGS.................................................................................... 5
SURGICAL/INVASIVE PROCEDURE EVENTS ........................................................................................... 9
Wrong Site Surgeries/Invasive Procedures ......................................................................... 10
Wrong Surgeries/Invasive Procedures ................................................................................ 11
Retained Foreign Object ...................................................................................................... 12
Pressure Ulcers ..................................................................................................................... 14
Falls ....................................................................................................................................... 15
Irretrievable Loss of an Irreplaceable Biological Specimen .............................................. 17
CONCLUSION ....................................................................................................................................... 19
APPENDIX A: REPORTABLE EVENTS AS DEFINED BY LAW ................................................................... 20
APPENDIX B ADVERSE EVENTS DATA, 2003-2017 ............................................................................... 24
APPENDIX C BACKGROUND ON MINNESOTA’S ADVERSE HEALTH EVENTS REPORTING LAW ........... 27
OVERALL STATEWIDE REPORT ............................................................................................................ 29
STATEWIDE REPORTS BY CATEGORY ................................................................................................... 29
FACILITY-SPECIFIC DATA ...................................................................................................................... 31
ADVERSE HEALTH EVENTS IN MINNESOTA ANNUAL REPORT | FEBRUARY 2018

EXECUTIVE SUMMARY
The release of the 14th annual summary of events reported under Minnesota’s adverse health
events reporting law shows that 342 adverse health events (Appendix A) occurred in Minnesota
hospitals and licensed surgery centers in this reporting period. While the results show some
areas of improvement, particularly in the areas of suicide/self-harm and pressure ulcers, several
of the original categories remain challenging, like falls and preventing surgical errors.
A closer look at the overall analysis of reported events shows an increase in fall-related deaths
and wrong site surgical/invasive procedure events, along with a decrease in pressure ulcer
reports. With respect to harm, there were 12 deaths and 103 serious injuries that resulted from
the reported events.
While in some areas the challenge to providers persists, there are several areas showing
improvement in this reporting year:
▪ There were no reported instances of physical assault on a staff or patient reported for the
first time in six years.
▪ The number of pressure ulcers declined to 120.
The adverse health events reporting system has been in place for fourteen years and serves as
a critical source of information on where, why and how events happen in Minnesota. While the
system provides an important longitudinal view of events across the years the focus of the
system remains not on counting the number of events, but rather developing a deeper
understanding of why these events occur and disseminating best practices to assist
organizations with preventing them in the future. The focus on learning has helped to create a
more transparent environment where these events and their causes can be broadly shared
across facilities to increase awareness of patient safety and to serve as a catalyst for
organizations to spur change in their own facilities. This report, the underlying reporting system
and analysis are an important tool for MDH to help ensure the safety of Minnesota’s health
care facilities.

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ADVERSE HEALTH EVENTS IN MINNESOTA ANNUAL REPORT | FEBRUARY 2018
As a result of this learning system, a number of actions were implemented in 2017:
▪ A safety alert was issued to all reporting facilities asking leadership to meet with a multi-
disciplinary team to perform a risk assessment and develop mitigation strategies for
preventing medication errors involving EPINEPHrine;
▪ A safety alert was issued to all reporting facilities asking leadership to collaborate with
wound ostomy continence nurses and with physical, occupational and respiratory therapists
to do an analysis of the barriers to better prevention of pressure ulcers, especially those on
the coccyx. This includes in-person observations and audits, as well as raising organizational
awareness of this critical safety issue;
▪ Hospitals implemented new best practices across settings of care because of both the
EPINEPHrine and pressure ulcer safety alerts. However, these safety alerts were issued
near the end of the reporting year, therefore the total impact is still unknown. MDH and
will continue to review statewide data for impact of these alerts.
▪ Began a statewide learning series where each month a webinar is hosted with experts on
different patient safety topics, such as biological specimen management, wrong site surgery
and pressure ulcer prevention. This series continues into 2018, and;
▪ Began to provide additional technical assistance to facilities to support their efforts to
identify root causes, create effective corrective action plans and support the dissemination
and adoption of prevention best practices.

All of this work was done collaboratively in conjunction with community partners, especially the
Minnesota Hospital Association and Stratis Health.
In 2018, MDH will continue efforts to improve patient safety in Minnesota, including, but not
limited to:
▪ Continuing to work with surgery and procedural experts to pilot time-out tools that will
allow for more streamlined adoption by facilities based on their procedural areas;
▪ Providing training opportunities for organizations on suicide and self-harm prevention, and;
▪ Providing training to organizations on an improved root cause analysis process, which will
assist them in conducting robust root cause analyses for these events, prioritizing areas of
risk, and developing effective and sustained action plans in response.

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ADVERSE HEALTH EVENTS IN MINNESOTA ANNUAL REPORT | FEBRUARY 2018

HIGHLIGHTS OF 2017 ACTIVITIES
The Minnesota Adverse Health Events Law directs the Commissioner of Health to review all
reported events, root cause analyses, and corrective action plans, and provide direction to
reporting facilities on how they can improve patient safety. In this work, MDH works closely
with a variety of stakeholders including the Minnesota Hospital Association (MHA), and Stratis
Health. Highlights of the 2017 activities include:
▪ MDH and its partners issued a safety alert to all reporting facilities asking leadership to
meet with a multi-disciplinary team to perform a risk assessment and develop mitigation
strategies for preventing medication errors involving EPINEPHrine;
▪ MDH and its partners issued a safety alert to all reporting facilities asking leadership to
collaborate with wound ostomy continence nurses, physical, occupational and respiratory
therapists to do an analysis of the barriers to better prevention of pressure ulcers on the
coccyx. This includes in-person observations and audits, as well as raising organizational
awareness of this critical safety issue;
▪ MHA hosted a pressure ulcer education conference. The topics included, but were not
limited to, prevention best practices, repositioning of critically ill patients, device related
prevention, teamwork, collaboration and patient and family engagement
▪ Stratis Health provided one-on-one consultation and technical assistance to reporting
organizations upon request and in response to opportunities to identify common causes
across events.
▪ Continued collaboration between MDH and its partners to support, provide and
disseminate evidence based best practices to support hospital and health system
improvement efforts.
▪ MDH and its partners began an Adverse Health Events (AHE) learning series where a
webinar is hosted with experts on different prevention areas, such as biological specimen
management and pressure ulcer prevention;
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ADVERSE HEALTH EVENTS IN MINNESOTA ANNUAL REPORT | FEBRUARY 2018
▪ As an outgrowth of several reported incidents of physical assault on staff at Minnesota
health care facilities, MDH, MHA and the Minnesota Sheriff’s Association co-convened a
group of healthcare and law enforcement professionals to address these issues. This group
met throughout 2017 and continues to meet into 2018. Best practices and tools/resources
will be shared statewide in early 2018 with hospitals and other healthcare facilities;
▪ MHA began work to develop medication reconciliation best practices for use statewide. This
work continues in 2018;
▪ MHA hosted a medication safety conference. The topics included, but were not limited to,
controlled substance diversion, culture of safety and medication reconciliation, and;
▪ With the creation of a new patient safety registry reporting system, MDH and its partners
have been able to create interactive dashboards, which allow users to examine
de-identified data from across the state. Users with similar event types can search root
cause analyses to create meaningful corrective action plans.
▪ MHA hosted a ‘Falls and Delirium Conference’. Local and national experts shared best
practices in fall and injury prevention. In addition, information was presented to support
delirium awareness building, prevention and interventions.

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ADVERSE HEALTH EVENTS IN MINNESOTA ANNUAL REPORT | FEBRUARY 2018

OVERVIEW OF REPORTED EVENTS & FINDINGS
In the 14 years of public reporting of adverse health events, the Minnesota Department of
Health has collected detailed information on more than 3,500 events. MDH and its partners
have used the findings from those events to identify strategies for improving processes of care
and preventing adverse health events. This annual report provides an overview of what the
most recent year of data can teach us about the risk points for adverse health events and the
best approaches for preventing them, with a highlight on the most commonly reported events.
For each of these categories of events, this report will discuss what has been learned about why
these events happened, what is being done to prevent them from happening again, and how
we can continue to learn from events that do occur.
Hospitals and ambulatory surgical centers that are licensed by MDH are required to report
adverse health events under this law. Federally licensed facilities, such as those operated by the
Veteran’s Administration or the Indian Health Service, are not covered by the law.
Figure 1: Reported Adverse Health Events 2008-2017
400
350 37 32
31 40
300 312 301 305 316 314 299 310
250 277 276
258
200
150
100
50
0
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Previously Reported Events New Events Added 2014

FREQUENCY OF EVENTS
Between October 7, 2016, and October 6, 2017, 342 adverse health events were reported to
MDH (Figure 1). Because the reporting system has changed over time, with several new event
categories added to the system in 2014, numbers from 2017 are not directly comparable to the
early years of the system. The events in those newer categories (32 of 342) are highlighted in
blue in the chart above.

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ADVERSE HEALTH EVENTS IN MINNESOTA ANNUAL REPORT | FEBRUARY 2018
PATIENT HARM
Of the reports submitted during this reporting period, 30 percent resulted in serious injury (103
events), while approximately four percent (12 events) led to the death of the patient (Figure 2).
Over the life of the reporting system, falls, medication errors and product/device malfunction
have been the most common causes of serious patient injury or death. The pattern was similar
in 2017; five of the 12 deaths were associated with falls, two were associated with a
product/device air embolism, two with the death of a neonate, one with suicide/attempted
suicide, one with a maternal death, and one with a medication error.
It is important to note that not all of the events under Minnesota’s adverse health events
reporting law have a threshold for the level of harm required to be reportable. Some events,
such as retained foreign objects or the loss or damage of a biological specimen, are required to
be reported regardless of the level of patient harm. However, all of these events are indicators
of potential system issues that could lead to harm.
Figure 2: Events with Harm 2008-2017
140
18 12
120 13
16 4
9
14
4 15
100 106
98 98 5 100 103
94 93
80 89
84 84
60
40
20
0
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Serious Injury Death

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ADVERSE HEALTH EVENTS IN MINNESOTA ANNUAL REPORT | FEBRUARY 2018
TYPES OF EVENTS
As in previous years, falls and pressure ulcers were the most commonly reported types of
events, accounting for 59 percent of all events reported (202 events). The four event types that
make up the surgical/invasive procedure category accounted for another 24 percent of reports
this year, with 83 events (Figure 3). Appendix B provides a summary of the number of events
reported in each category over the life of the system.
Figure 3: Events by Category 2017
140
120
120
100
82
80
60
36
40
27 26
19
20 11
7 5 4 3 2
0

ROOT CAUSES OF ADVERSE EVENTS
When a reportable adverse event occurs, facilities are required to conduct a root cause analysis
(RCA). This process involves gathering a team to closely examine the factors and circumstances
that led to the event. These factors can include such things as miscommunication, lack of
compliance with or lack of clarity in policies or procedures, and problems with the underlying
organizational culture. This type of analysis seeks to identify and address the root causes of
events, as opposed to simply addressing their symptoms or applying a quick technical solution.
By focusing corrective action on a specifically identified root cause, the recurrence of similar
problems can be prevented.

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