Enacted in 2003, the law requires hospitals and ambulatory surgery centers to track and study 28 types of serious adverse events, including wrong-site surgeries, bed sores, falls, foreign objects left inside a patient after surgery, medication errors and suicides. The reporting system marks Minnesota's first statewide attempt at measuring how often preventable errors occur.
“Our evaluation confirmed that this joint effort between MDH, its partners and Minnesota's healthcare facilities has helped to shine light on what was often a hidden problem,” Dr. Ed Ehlinger, Minnesota commissioner of health, said in a news release. “By doing so, it has not only contributed to better outcomes, faster responses and better practices, but it has also resulted in a significant change in mindset, from acceptance that some errors are unavoidable to an expectation that those errors can be prevented.”
Deaths from preventable medical errors in the state reached a high of 25 in 2006 and a low of five in 2011. Though it remains down from its 2006 high, that number bounced back up to 15 during 2013. The biggest driver was falls, which were related to 10 of those deaths.
According to the yearly report released in January, “it was found that facilities are not consistently putting all appropriate interventions in place to prevent falls or fall injuries, and interventions, such as bed alarms, are not effectively alerting staff in time to prevent an injury from occurring.” The department of health plans to focus increased effort on standardizing those interventions in the coming year.
Other recommendations from the 10-year report include additional training opportunities for the most common events, new methods and tools for facilities to data share, and expanded efforts toward transparency, learning and public reporting across all healthcare settings.
“Overall, the 10-year look back shows encouraging progress as does parts of the 2013 report,” Diane Rydrych, director of the Minnesota Department of Health health policy division, said in the release. “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.”
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