In 2003, Minnesota established one of the first state public-reporting programs in which hospitals and ambulatory surgery centers are required to report instances of serious harm and deaths at their organizations. That was in response to recommendations made three years earlier in To Err is Human: Building a Safer Health System. The report called for a mandatory and standard nationwide reporting system of adverse events.
Twenty years since the report, only 28 states have adverse-event reporting systems, according to the most recent report from the National Academy of State Health Policy, and there is no national database.
What that means is that there is no standard way to know how many people die in the U.S. because of medical errors. There is also no national database to glean knowledge from, and there are no numbers that can be used to hold any one organization accountable or in high regard.
Minnesota's legislators selected NQF's never events because they thought the IOM's recommendations would become a reality. To Err is Human called on NQF to develop a set of patient-harm events that states would all follow so comparisons could be made nationally.
"That hasn’t really come to pass," Rydrych said.
Of the 28 states that have an adverse-event reporting system, just eight follow the NQF list. The other states either implemented a modified or partial NQF list of events or their own unique lists.
Given the questions surrounding the figures in the most recent report, the state is now exploring how its reporting program can be modified. “Fifteen years ago we were just trying to prove we can report safety at all, and it was a huge lift to develop a system … but the (patient) risks are different now," she said. "How does the system need to evolve to meet where the needs are now?"
Right now, Minnesota requires all hospitals and ambulatory surgery centers to conduct a root cause analysis for each event that occurs and how to prevent it from recurring. "It's a lengthy process," said Dr. Timothy Morgenthaler, vice chair of quality and affordability at Mayo Clinic.
At Mayo Clinic Hospital, the system's flagship facility in Rochester, Minn., 41 never events occurred, according to the state's most recent report. Of those, 11 were pressure ulcers, 10 were wrong surgeries and six were falls. One fall killed a patient, while five caused serious harm. While Mayo Clinic takes every never event seriously, there are some events that aren't helped by conducting a root cause analysis, Morgenthaler said.
For example, pressure ulcers typically happen now only in two circumstances: to patients in the intensive-care unit with medical devices or those with multisystem organ failure.
"It requires a great amount of care and even with micro-turning, we aren't able to (prevent the patient) from developing a pressure injury," Morgenthaler said.
Falls are also difficult to prevent. Patients in hospitals are much sicker and more frail than previous years, but mobility is still encouraged to speed recovery.
"We can't really say to the patient, 'You need to be in bed,' " said Dr. Rahul Koranne, chief medical officer of the Minnesota Hospital Association. "If we did that we'd have zero falls, but that wouldn't be the right thing to do in serving our patients."
Given the challenges with preventing some events and the resources it takes to report them, Morgenthaler wondered if the program should look at other areas of harm.
"At some point doing the measurement and reporting can actually be helpful and at other times it can be burden," he said. "Are we really going to learn more and prevent more or should we take those same resources and put it into something else?"