Minnesota lists 24 outpatient adverse events

The Minnesota Department of Health has released its third annual report, Adverse Health Events in Minnesota. The report, containing events from a 12-month period starting October 2005, showed 154 total adverse events.

Of the 154 events in the most recent report, 129 involved inpatients, one didn't involve a patient, and 24 involved outpatients in various settings, including hospitals and surgery centers. The 24 outpatient adverse events include:

  • 12 wrong-site surgeries/invasive procedures;
  • five retained foreign objects;
  • four wrong procedures;
  • one medication error;
  • one wrong patient;
  • one intra-/post-op death.

"The intent is for surgery centers to implement best practices that have resulted from this reporting system in order to eliminate 'never' events," says Traci Albers, MBA, president of the Minnesota Ambulatory Surgery Center Association and executive director of High Pointe Surgery Center in Lake Elmo.

The information from the report helps staff understand why errors occur and what can be done to prevent them, Albers says. For example, it has been helpful to understand why wrong-site surgeries continue to occur in facilities, she says. "We are learning that it is a number of contributing factors," Albers says. "Surgery centers have implemented the nationally accepted safety recommendations, but are discovering that our processes must be more defined and more focus needs to occur during the timeout prior to the procedure."

The full report is available at www.health.state.mn.us/patientsafety. Under "Spotlight," click on "Adverse Health Events in Minnesota Report, January 2007."