Minnesota hospitals' report on "never events" released

Stressing that it is to be used as a performance improvement tool and not for regulatory action or to make comparisons, the Minnesota Dept. of Health released its first hospital adverse event report.

The report, compiled between July 1, 2003, and Oct. 6, 2004, measured how many times the 27 "never events" developed by the National Quality Forum occurred in Minnesota hospitals. The list includes events that should never happen and can be prevented, such as wrong-site surgery, stage 3 or 4 pressure ulcers acquired after admission, and the misuse or malfunction of medical devices. In all, 99 events were reported, resulting in 20 patient deaths and four cases of serious disability.

"I think this a good beginning, and they are to be congratulated," said NQF President and CEO Kenneth Kizer, MD. "This type of transparency is the wave of the future. This is the right thing to do and clearly the way things are going." He added that Connecticut and New Jersey also incorporated the NQF never list into the reporting laws they passed last year.

Marie Dotseth, MHA, the Minnesota health department's senior policy adviser for patient safety, said the reporting law is working as intended.

"The fear was that we were just going to scare people, but that hasn't happened at all," Dotseth said. "People are very supportive about hospitals' efforts to uncover these things and take corrective actions. The most common critical thing we've heard is 'This isn't enough.' "

Hospitals included in the report range in size from 10 beds to 1,700. Individual facility adverse event totals are included in the report, along with the hospital's number of beds, surgical procedures and patient days.

"We want this information put in context," Dotseth said. "The size of the facility matters. A 1,700-bed hospital is more likely to experience these events than a 50-bed facility."

She added that a priority for 2005 would be ensuring that hospitals are "uniformly thorough" in performing a root-cause analysis of why events that, by definition, are never supposed to happen actually happened.

In addition to annual reports, the Minnesota health department issues safety alerts with recommendations for corrective action. A safety alert was issued in April 2004 when officials spotted relatively high numbers of surgical events and pressure ulcers.

Despite national efforts to prevent surgical errors, the report included 13 cases of wrong-site surgeries, five of performing the wrong procedure, one of operating on the wrong patient and 31 cases of leaving foreign objects inside the patient.

"Why is that still an issue?" Dotseth asked. "Whatever it is we're doing, it's not enough, but we don't have to wait until next year to act."

Minnesota Medical Assn. CEO Robert Meiches, MD, said his organization supported the adverse event reporting law, but he added that doctors were a little wary about it at first.

"Some physicians were concerned when the media focused on physicians as being the problem as opposed to systems being a problem," he said. "These are not physician errors, these are hospital errors. The purpose of this is to improve -- it's not to highlight who's doing good or bad."

Dr. Meiches also said the bill allows free discussion of adverse events that is free from legal discovery, so doctors are protected from having that data used against them in civil court.

There was some discussion that, compared with some national studies, 20 patient deaths from adverse events seemed low. Dotseth said this could be because those studies included deaths from all adverse events, while the Minnesota report calculated deaths from only 27 specific events.