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The Reporting of Adverse Health Events in Minnesota


The Reporting of Adverse Health Events in Minnesota MNASCA 2012 Annual Conference Diane Rydrych Minnesota Department of Health No questions on this one Was harm ... – PowerPoint PPT presentation

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Title: The Reporting of Adverse Health Events in Minnesota

The Reporting of Adverse Health Events in
  • MNASCA 2012 Annual Conference
  • Diane Rydrych
  • Minnesota Department of Health

  • Background on reporting system
  • Reporting requirements
  • Overall/ASC data
  • Case studies/discussion
  • Upcoming events
  • Discussion questions

  • IOM report To Err is Human
  • 44,000 98,000 deaths/year
  • No one public trigger event that caused
    concern, but there were several media stories
    about errors
  • Formation of MAPS in 2000 MDH, MHA, MMA

Minnesotas Reporting Law
  • Established in 2003 (ASC 2004)
  • Hospitals, ASCs, Boards
  • Annual report each January
  • Number of events by category at each facility
  • Outcome of event
  • Consumer companion report

Goals of the law
  • Not to punish errors by health care
    practitioners or employees
  • Insteadto balance quality improvement and
    accountability for public health safety
  • Focus on learning and transparency

Advisory Groups
Registry Calls to Action Sharing DB
Safety alerts
Administration Reporting Evaluation
Outreach Goal setting Updates Trends
RCA review
What must be reported?
  • Any of the 28 events defined in law
  • Within 15 working days after discovery of the
  • Within 60 days, findings of a root cause analysis
    and a corrective action plan
  • NO identifying information for any health
    professionals, employees or patients is included

Examples of reportable events (from list of 28
Serious Reportable Events created by NQF)
  • Care Management
  • Medication error
  • Maternal death
  • Death from hypoglycemia
  • Serious pressure ulcers
  • Environmental Events
  • Death from electric shock
  • Wrong gas delivered
  • Patient burns
  • Patient falls
  • Criminal Events
  • Abduction
  • Sexual assault
  • Surgical/procedure Events
  • Wrong surgery
  • Retention of foreign object
  • OR or Post-op death
  • Product or Device
  • Contaminated drugs or blood
  • Air embolism
  • Patient Protection
  • Infant discharged to wrong person
  • Patient elopement

What must be reported?
  • RCA findings and corrective action
  • Why did the event happen?
  • What role did staffing, communication, training,
    etc play in the event?
  • What are you doing to keep it from happening
  • Time, location, injury
  • Event-specific questions

How does the system work?
  • Secure, web-based registry
  • Review of all RCAs and corrective actions
  • Focus on learning and quality improvement
  • Trend analysis, safety alerts
  • Existing MDH regulatory responsibilities still in

Adverse Events 2003-2011
Adverse Events 2011
ASC events
ASC events by type (all years)
ASC events
Patient Harm ASCs (all years)
2012 Reportability Survey
  • Patient entered the hospital as an outpatient for
    a dialysis fistula graft de-clotting procedure.
    The patient has a fistula graft in each arm,
    however the procedure was to be performed on the
    right arm. Prior to the procedure, the
    radiologist injected the local anesthetic into
    the left arm. The patient questioned the
    injection the radiologist realized that the
    local anesthetic was injected in the incorrect
    side and proceeded to do a local injection on the
    right. The procedure continued as planned.
  • Survey Results
  • Reportable 72
  • Not Reportable 26
  • Need more information 2

2012 Reportability Survey
  • A cesarean section was planned for delivery of
    twins at 39 weeks along with a tubal ligation.
    Patient consented the day of surgery for cesarean
    section and tubal ligation. Complications
    occurred during the c-section. The twins were
    successfully delivered, however, the tubal
    ligation was not completed due to concerns about
    the mothers health.
  • Survey Results
  • Not Reportable 86
  • Reportable 10
  • Need more information 4

2012 Reportability Survey
  • Patient underwent a breast biopsy under local
    anesthesia. An inspection of the needle
    immediately prior to the procedure showed that it
    was intact. During the procedure, a 5 mm piece
    of the biopsy needle broke off under the skin.  
    This was discovered at the end of the procedure,
    while the patient was still in the procedure
    room. While an inspection of the needle
    immediately after the procedure clearly showed
    that a portion had broken off, the radiologist
    did not see a needle retained on x-ray.
  • Survey Results
  • Not Reportable 76
  • Reportable 20
  • Need more information 4

2012 Reportability Survey
  • Patient admitted to perioperative area for
    vaginal hysterectomy on same date. Foley urinary
    catheter and vaginal packing in place
    post-operatively. Patient admitted for overnight
    observation, with physician orders for removal of
    foley urinary catheter and vaginal packing prior
    to discharge. Foley catheter removed but vaginal
    packing was not removed. Patient later reported
    to surgeons office during follow up call that
    she had removed the vaginal packing herself, at
    home on the day of discharge, when she noted
    difficulty voiding.
  • Survey Results
  • Reportable 87
  • Not Reportable 13
  • Need more information 0

2012 Reportability Survey
  • Patient seen in surgeons clinic for removal of
    cataract and replacement of lens. Patient and
    surgeon agreed that patients vision would not be
    corrected to 20/20 because patient had never had
    20/20 vision and did not want this change. The
    patient consented to the correction of less than
    20/20 and the surgery was scheduled. Physician
    ordered and implanted a lens that corrected
    vision to 20/20. After discussing with the
    surgeon, patient decided that he felt comfortable
    with the correction and did not want to have a
    second procedure.
  • Survey Results
  • Reportable 65
  • Not Reportable 29
  • Need more information 6

Key Findings
  • Problems are almost always at the system, not
    individual, level
  • Most adverse events happen because of breakdowns
  • Communication
  • Policies/Procedures
  • New challenges related to EHRs, focus on costs,
    health reform, etc

Key Findings
  • Focusing on the causes of events is the only way
    to prevent their reoccurrence
  • Sharing information/best practices works
  • Need to create a culture of learning and
  • Speak up about unsafe situations
  • Be accountable for following safe practices

Still room to grow.
  • Facilities still need support in getting deep
    enough in their analysis
  • 5 Whys
  • Measurement of corrective actions continues to be
    a challenge
  • Hierarchy of corrective actions

2012 Priorities
  • Time Out Campaign
  • Procedural areas
  • Leadership Engagement
  • Organizational Culture

Upcoming Events
  • May 2 statewide conference call
  • Early May MDH Patient Safety mini-grants
  • May 31 RCA training, Duluth

  • What are the biggest patient safety issues in
    your facility?
  • How can we support your work?

For More Information
  • Diane Rydrych
  • Minnesota Department of Health
  • 651-201-3564