Adverse Event Report

The 12th annual Adverse Events Health Report, put out by the Minnesota Hospital Association, (MHA) was released on Fri., Feb. 19. Initiated by the MHA and the Minnesota Department of Health (MDH) and created through state legislation in 2003, the system is the first in the nation to be built on the National Quality Forum's list of reportable adverse events. The MDH and MHA produce an annual report of adverse events that have occurred in Minnesota hospitals, ambulatory surgery centers and regional treatment centers. Statewide adverse events have a wide range - from surgical errors to medications to pressure ulcers.

Mille Lacs Health System had one adverse event in the reporting period of Oct. 2014  ̶ Oct. 2015. A patient admitted to MLHS’s “Swing Bed” (or transition bed) program fell. The “Swing Bed” is for patients who are not quite ready to go home yet but still have an in-patient nursing or rehabilitation need to build up their strength and/or independence before going home.

The patient was on a “blood thinner” and the fall resulted in the patient having to be transferred to another hospital, where the patient died from a brain bleed. Kucera stated that since the incident, a root cause analysis was done and an action plan put into place. “Keeping the family at the center of our care is of prime importance to us,” Kucera said. “We did a lot of education with families of those who are on blood thinners to warn them of the risks. Also, we revamped the fall risk assessment tool nurses use to make sure we identify patients who are at risk because of blood thinners and anticoagulant therapy.”

Mille Lacs Health System Quality Manager Greg Larson says  part of what makes the Adverse Event reporting important for medical facilities is that it provides a process for learning from others, and improvement. Through hospital participation in the MHA Patient Safety Registry, hospitals share best practices, identify common issues and collaborate on finding solutions together. Hospitals also gain access to benchmark reports and action steps from peer hospitals. “Avoiding mistakes is a top priority, but to learn from them if they happen is what the takeaway should always be,” Larson said.

Ninety percent of facilities in the state self-report safety event and medical error information. The reporting is needed by hospitals to become more aware of medical errors, catch those errors, and encourage staff at medical facilities to report these events without fear of reprisal. MHA has long been spearheading patient safety efforts, and hospitals have shown remarkable commitment to improving patient safety.

We are holding hands across all health systems  ̶  big and small, urban and rural,” said Dr. Rahul Koranne, chief medical officer of the Minnesota Hospital Association (MHA). “The collaboration between hospitals, health systems, MHA and MDH results in robust communities of nurses, physicians, care teams and hospital staff who work diligently year-round to provide a system for learning and continuous quality improvement.”

Mille Lacs Health System has gotten awards in the past for fall reduction, patient safety, and participates with the MHA regarding best practices. “We are deeply sorry that his event occurred, and we take transparency seriously,” Kucera said. “With the increasing complexity regarding the populations we serve, it’s important for us to closely identify all risks and learn from any unfortunate experience that may occur. There is a strong culture of safety at MLHS and we’re absolutely committed to creating the safest hospital environment possible.”