MLHS reports adverse events

The 13th annual Adverse Events Health Report, put out by the Minnesota Hospital Association, (MHA) was released on Fri., Feb. 17. It was initiated by the MHA and the Minnesota Department of Health (MDH) and created through state legislation in 2003. In the 13 years of public reporting of adverse health events, the Minnesota Department of Health has collected detailed information on more than 3,200 events. This annual report provides an overview of the most recent year of data and the identified risk points for adverse health events. 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. 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.

Mille Lacs Health System had two adverse events in the reporting period. These events were related to falls in the Senior Care Unit, a specialized unit for Geriatric Psychiatry evaluation. MLHS COO Kim Kucera said the two falls were unfortunate events, and that steps were immediately taken to identify the possible root causes of the situations, as well as ways to prevent such occurrences from happening again.

“Behind every event, we know there is a patient and a family,” Kucera said. “And while patients are in our care, we take every precaution to maintain their safety. We are deeply sorry when events occur.” Kucera said there is a strong culture of patient safety at MLHS, and in this behavioral health unit, as well as elsewhere in the facility, best practices are followed. “This type of senior population especially is at risk for falls, and this challenges us to continue to be committed and vigilant about causes and preventions.”

Dr. Rahul Koranne, chief medical officer of the Minnesota Hospital Association (MHA) said that the true value of the reporting system comes from its ability to use the information to provide a strong system for learning and continuous quality improvement. “It’s a year-long learning system for all of us,” Koranne said. He went on to note that he is encouraged by the declining state-wide numbers regarding events such as overall deaths, deaths from falls, and medication errors. “I’m proud that we are in a state that tries to prevent issues, as well as learn from errors. We put patients and family first, and this is our foundation for safety and quality improvement."

The results of the statewide report can be viewed at