news release
May 30, 2024
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The number of reportable health incidents at Minnesota hospitals, licensed ambulatory surgery centers and community behavioral health hospitals increased for the fourth consecutive year in 2023, according to the latest health incident data released today by the Minnesota Department of Health (MDH).
Minnesota's mandatory health hazard reporting system requires certain types of facilities to report any time a health hazard occurs and to conduct a root cause analysis to determine the cause and contributing factors. The system includes 29 often preventable errors that could result in serious injury or death. The goal of the system is to balance quality improvement with accountability and transparency while creating opportunities for health care providers to learn from each other about how to prevent health hazards.
Prior to 2021, the overall number of events remained stable. However, the total number of reported health hazard events (610) and the total number of serious injury hazard events (222) both reached record highs in 2023.
“While health incidents in these settings remain rare relative to the overall number of cases, we are concerned by current trends in both the number of cases and their severity,” said Minnesota Health Commissioner Dr. Brooke Cunningham. “We remain committed to conducting these analyses and advocating for changes in how care is delivered to improve outcomes and ensure patient safety for all Minnesotans.”
The data is provided in a new chartbook format and includes reports of adverse health events collected from health care providers from Oct. 7, 2022 to Oct. 6, 2023. The 2023 data shows that the total number of adverse events increased by 38 compared to 2022, and is now up more than 166% since 2019, the last year Minnesota reported a decrease in adverse events.
Total number of reported health events from 2014 to 2023
In addition to an increase in the total number of reported adverse events, the 2023 data also revealed an alarming increase in serious injury events (recorded events associated with serious injury or death): After decreasing in 2022, the number of serious injuries or deaths increased in 2023 to a record total of 238, accounting for almost 40% of all recorded events.
Number of serious injury health events reported from 2014 to 2023
Since the COVID-19 pandemic, there has been a continuing trend of patients staying in hospital longer. One factor contributing to the increase in adverse health outcomes in 2023 is the continued increase in adjusted hospital days. Longer hospital stays increase the risk of experiencing adverse health outcomes.
Adjusted patient days during the 2023 reporting period increased from 5.5 million in 2022 to 5.9 million in 2023. This increase in hospital days can be attributed to increased patient complexity due to delayed care and Minnesota's aging population.
However, post-acute care staffing shortages have led to a shortage of follow-up care beds and delayed discharges, contributing significantly to longer hospital stays, as patients are admitted to emergency departments or other areas of the hospital that are not suitable for inpatient care. Additionally, some hospitals reported that staffing shortages have led to the prioritization of critical care responsibilities, leaving fewer staff available to handle patient care needs such as positioning and mobility.
“We understand that many factors are at play, and the strain on our health care delivery system that has been highlighted by the COVID-19 pandemic is very real,” Cunningham said, “but the data shows that these cases have increased significantly over the past five years, and we as a state must continue to make progress toward preventing them.”
Similar to previous adverse event data reports produced by MDH, pressure ulcers and falls were the most common reported events, with falls accounting for the majority of the overall increase, increasing reported events by more than 21% to 96 in 2023. Lost or damaged biological specimens and post-surgical residue were also reported in greater numbers.
Number of reported health events by category, 2014-2023
“Every adverse health event impacts the lives of patients and their families and highlights challenges in our health care system, which are exacerbated by severe financial and staffing shortages in hospitals and health systems and significant increases in patient length of stay,” said Dr. Rahul Coranne, president and CEO of the Minnesota Hospital Association. “But the latest reports on these events show that health care providers are even more committed to the surest path to improvement: tracking what went wrong, learning why it happened and working to do better.”
MDH continues its efforts to address both hospital-specific and system-wide issues that impact safety. MDH and its partners have begun to incorporate new methods of data collection and analysis to further improve the quality of adverse health event data. The robustness of these efforts will be even more critical in upcoming reports as MDH further implements Phase II of the Adverse Health Events System Evolution Project. The goal of this project is to evolve and update the system to better meet the needs of Minnesota's changing health care environment.
More information, including publications and annual reports, is available on the Minnesota Adverse Event Reporting System website.
-MDH-
For media enquiries please contact:
Gary Bowman
MDH Communications
651-529-5164
garry.bowman@state.mn.us
