Adverse health events continue to rise in Minnesota for 4th straight year, says MDH
MINNEAPOLIS — The number of reported adverse health events in Minnesota hospitals, licensed ambulatory surgical centers and community behavioral health hospitals has continued to rise for the fourth straight year, according to the Minnesota Department of Health.
In Minnesota, healthcare providers must report adverse health events through a reporting system. When an adverse health event report is made in the system, it requires that a root cause analysis is conducted in order to identify the causes and contributing factors that led to the event.
The system flags 29 often preventable errors that could have led to serious injury or death. The goal of the system is to balance quality improvement with accountability and transparency while developing opportunities for providers to learn from each other about how to prevent adverse health events.
According to the MDH, prior to 2021, the overall number of events had been stable.
However, in 2023, there was a total number of 610 reported adverse health events and 222 adverse events that resulted in serious injury, both are new highs in each category.
"Though adverse health events in these settings continue to be rare relative to overall patient volume, we are troubled by the current trend lines of both the number of adverse events and their severity," said Minnesota Commissioner of Health Dr. Brooke Cunningham. "We remain committed to conducting these types of analyses and advocating for changes in how care is delivered to improve outcomes and ensure patient safety for all Minnesotans."
Data collected from health care providers between Oct. 7, 2022 and Oct. 6, 2023 show that the total adverse events has increased by more than 166% since 2019, the last year Minnesota reported a decrease in adverse events.
MDH also pointed out in their report that they are also seeing a worrying rise in events that resulted in severe injury – a recorded event that is associated with serious injury or death.
After decreasing in 2022, the number of severe injuries or deaths increased in 2023 to an all-time high total of 238 and comprised nearly 40% of all recorded events, said the MDH.
Another point of interest in MDH's report is the continuing trend of patients staying in medical facilities longer. This has been a trend observed since the COVID-19 pandemic.
According to MDH, a portion of the 2023 increase in adverse health events can be attributed to the continued growth in adjusted patient days. Prolonged time in the hospital has been linked to an increased risk of experiencing an adverse event.
Discharge delays due to limited bed availability are also playing an important role in contributing to longer patient stays.
The MDH points out that delays in discharging patients can lead to patients being boarded in emergency departments and other locations within the hospital that are not suited for inpatient stays.
Also, some hospitals have reported that workforce shortages pushed them toward prioritizing critical care responsibilities, leaving fewer staff members to assist with patient care needs, such as repositioning and mobility.
"We understand there are many factors at play, and the strains on our care delivery system that the COVID-19 pandemic exposed are very real," Cunningham said. "However, the data show that these events have grown significantly over the past five years, and we need to keep working as a state to make progress in preventing these types of harm."