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Minnesota Department of Health releases statewide adverse health events report

BEMIDJI — Two patients at Sanford Bemidji Medical Center suffered falls that led to serious disability, according to a report released Thursday by the state.

As the Minnesota Department of Health released its statewide adverse health events report, it also marked the 10th anniversary of the reporting system that tracks 28 types of serious events, such as wrong-site surgeries, severe pressure ulcers, falls or serious medication errors.

“It has not only contributed to better outcomes, faster responses and better practices, but it has also resulted in a significant change in mindset, from acceptance that some errors are unavoidable to an expectation that those errors can be prevented,” said Minnesota Commissioner of Health Dr. Ed Ehlinger in a press release.

The most recent report tracked events that occurred between Oct. 7, 2012, and Oct. 6, 2013.

The total number of events reported statewide was 258, a decline of 18 percent from the previous year, according to the report.

That marked the first time the total number of events fell below 300 since definitional changes in 2007 broadened reporting, the Department of Health said.

However, the decline in total events in 2013 did not result in a decline in the number of deaths for 2013. There were 15 deaths reported, 10 of which were related to falls.

“Reducing falls and reducing harm from falls continues to be one of the most difficult hazards to eliminate, despite significant focus and adoption of best practices by health care facilities,” the press release stated.

Sanford Bemidji Medical Center reported two adverse health events, both of which were patient falls that led to serious disability.

“Our goal is always to have zero events,” said Lindsey Wangberg, hospital spokeswoman. “When something does happen, it is very serious, no matter what the case is.”

When such events occur, the hospital self-reports the event, and hospitals throughout the state together learn from the incident.

“We look at benchmarks across the state … taking those lessons learned to ensure such events don’t happen again,” Wangberg said.

The 10-year evaluation of the program calls for Minnesota to develop additional training opportunities for the most reported events, develop new methods and tools that facilities can use to share data, and work to expand commitment to transparency, learning and public reporting to other health care settings, the press release stated.