Minnesota report card on patient safety

An occasional snapshot of current facts and trends in medicine.

Quick View. Posted March 27, 2006

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The state is now on record for reporting hospital "never events."

Top 10 occurring "never events" for each annual report 2005 2006
Foreign objects left in a patient after surgery 31 26
Stage 3 or 4 pressure ulcers acquired after admission 24 31
Surgery performed on the wrong body part 13 16
Medication error resulting in patient death or serious injury 6 7
Patient death due to fall in hospital 8 3
Wrong surgical procedure performed on a patient 5 8
Misuse or malfunction of a device in patient care resulting in death or serious disability 4 4
Death during or immediately after surgery of a normal, healthy patient 2 1
Patient suicide or attempted suicide resulting in serious disability 2 1
Surgery performed on the wrong patient 1 1

In 2003, Minnesota became the first of four states to require that hospitals report all 27 "never events," medical errors or adverse events, as defined by the National Quality Forum and other patient-safety experts.

In January 2005, the Minnesota Dept. of Health issued its first public report of hospital-reported never events that occurred between July 2003 and Oct. 6, 2004, both in the aggregate and at the individual hospital level. This February, the department issued its second annual report, which covers the period Oct. 7, 2004, to Oct. 6, 2005.

Both reports are available on the Minnesota Dept. of Health's Web site (link).

Source: "Adverse Health Events in Minnesota," 2005 and 2006 reports, Minnesota Dept. of Health

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