Pandemic impacts continue to affect increasing number of reported adverse health events
The latest Adverse Health Events (AHE) report (PDF) from the Minnesota Department of Health (MDH) shows the number of reportable adverse health events in Minnesota hospitals, ambulatory surgical centers and community behavioral health hospitals increased during the 2022 reporting period. The report notes that this is likely due to ongoing pandemic-related affects that continue to be felt across the state’s health care system.
Minnesota’s mandatory adverse health event reporting system includes 29 often preventable errors that could lead to serious injury or death. The goal of the system is to balanced quality improvement with accountability, while developing opportunities for providers to learn from each other about how to prevent adverse events.
Prior to 2021, the overall number of events had been stable. However, for the second year in a row MDH observed a rise in the number of incidents.
The report is an analysis of data collected from health care providers from Oct. 7, 2021, to Oct. 6, 2022. It includes a total of 572 events, up from the 508 recorded in 2021 and 190 more than the 383 events reported in 2020. And though the data showed a drop in the number of serious injuries, the 21 reported deaths are the most since 2006, when 24 deaths were recorded.
Number of events with harm
Many of the issues impacting adverse health events in 2022 were related to broad, systemic challenges in the health care delivery system. According to the report, these challenges were magnified by both the added strain of the pandemic, and by limited resources and systems within individual hospitals.
Several events noted in the MDH report are tied to delays or barriers in seeking care, resulting in higher patient complexity and longer intensive care/critical care stays compared with previous years. These longer stays contributed to hospital patient volumes frequently exceeding the number of inpatient beds available and patients being boarded in emergency departments and other locations not otherwise designed for inpatient stays.
Workforce shortages across the health care continuum also continue to impact outcomes. Staffing shortages both limit the number of hands available to assist with patient care needs, such as repositioning and mobility, and create backups in transfers of care across facilities. The result is delayed patient discharges to the next setting of care, further increasing length of stays.
"It's clear from this latest Adverse Health Event report that systemic and pandemic-related issues continue to impact patient safety in Minnesota," said Commissioner of Health Dr. Brooke Cunningham. "These types of analyses and the corrective action plans MDH staff advocate for when providing direction to our health care partners are important tools for improving outcomes for Minnesotans seeking care."
Number of events reported by category
As in years past, pressure ulcers and falls were the most common events reported. Pressure ulcers, which can sometimes be associated with longer stays, drove most of the overall increase noted in the report, while falls decreased slightly compared to 2021.
“Each and every adverse health event touches the lives of our patients and their families and highlights the ongoing complexities and challenges in our health care system. These hurdles have been exacerbated by the global pandemic and historic workforce shortages," said Dr. Rahul Koranne, president and CEO of the Minnesota Hospital Association. " Despite these extraordinary circumstances, Minnesota’s hospitals and health systems remain steadfast in their commitment to transparent reporting and are always focused on providing the safest, highest- quality care possible.”
MDH is committed to continuing its work to address both hospital-specific and systemic issues that impact safety. In 2023, MDH and its partners will be exploring new methods to collect and analyze data. This includes equity issues that may lead to an increased risk of adverse health events, additional focus on workforce solutions and initiatives, and embarking on Phase II of the Adverse Health Events System Evolution project, which aims to evolve and update the system to better suit the needs of the changing health care environment in Minnesota.