MLHS reports adverse events


by Mary Rains

Mille Lacs Health System

The 14th annual Adverse Events Health Report, put out by the Minnesota Hospital Association, (MHA) was released on Thurs., Feb. 22. It was initiated by the MHA and the Minnesota Department of Health (MDH) and created through state legislation in 2003. This annual report provides an overview of the most recent year of data. 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.

Events such as those relating to surgery, pressure ulcers, and falls are among the many different types reported.

Mille Lacs Health System had one adverse event in the reporting period, which was October 7 of 2016 to October 6 of 2017. This event was related to a fall in the Senior Care Unit, a specialized unit for Geriatric Psychiatry evaluation.

“We are deeply sorry that this event occurred, and we take this kind of transparency seriously,” MLHS COO Kim 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 while patients are in our care, we want them to be in the safest environment possible.”

“Our interdisciplinary team met to identify possible causes,” said Senior Unit Directory and R.N. Jane Larson. “We determined that this type of fall could not be prevented due to the mental health issue of the patient.” Larson went on to say the specialized unit visualizes patients every 15 minutes at night, utilizes low beds, uses “arm’s reach” practices, and has completed MHA’s Behavioral Health Falls Road Map. “Our Senior Care Unit tries to strike that delicate balance between preventing falls that result in injury, while still encouraging a patient to function at the highest level possible.”

The report shows some trends, one of which is that falls in general are up this year in healthcare facilities across the state. Dr. Rahul Koranne, Chief Medical Officer of the Minnesota Hospital Association (MHA) said, “It’s a year-long learning system for all of us, and we learn from each other in real-time. 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