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The number of reportable adverse events in Minnesota hospitals, ambulatory surgical centers and community behavioral health hospitals has been slowly increasing for the last five years, and these events reached their highest number, 384 events out of five million patient days, between October 2017 and October 2018.

The annual adverse health events report is part of Minnesota’s strong public-private partnership dedicated to quality improvement. Though the number of events increased again in 2018, these events remained very rare and their very low frequency—far below one percent of hospitalizations—has remained steady over the past 15 years of reporting.

Minnesota’s Adverse Health Events reporting system tracks 29 serious events, such as wrong-site surgeries, severe pressure ulcers, falls and serious medication errors, which should rarely or never happen. 

“This system has given us a much deeper understanding of how and why adverse events occur, and it has helped create a culture of learning and improvement across Minnesota,” said Minnesota Health Commissioner Jan Malcolm. “It is clear there is still more to do to keep patients safe every time they receive care. . . .

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