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PROFESSIONAL ISSUESMinnesota hospitals' report on "never events" releasedEnsuring that the facilities are thorough in performing root-cause analysis of adverse events will be a 2005 priority.By Andis Robeznieks, AMNews staff. Feb. 21, 2005. Stressing that it is to be used as a performance improvement tool and not for regulatory action or to make comparisons, the Minnesota Dept. of Health released its first hospital adverse event report. The report, compiled between July 1, 2003, and Oct. 6, 2004, measured how many times the 27 "never events" developed by the National Quality Forum occurred in Minnesota hospitals. The list includes events that should never happen and can be prevented, such as wrong-site surgery, stage 3 or 4 pressure ulcers acquired after admission, and the misuse or malfunction of medical devices. In all, 99 events were reported, resulting in 20 patient deaths and four cases of serious disability. "I think this a good beginning, and they are to be congratulated," said NQF President and CEO Kenneth Kizer, MD. "This type of transparency is the wave of the future. This is the right thing to do and clearly the way things are going." He added that Connecticut and New Jersey also incorporated the NQF never list into the reporting laws they passed last year. Marie Dotseth, MHA, the Minnesota health department's senior policy adviser for patient safety, said the reporting law is working as intended. "The fear was that we were just going to scare people, but that hasn't happened at all," Dotseth said. "People are very supportive about hospitals' efforts to uncover these things and take corrective actions. The most common critical thing we've heard is 'This isn't enough.' " Hospitals included in the report range in size from 10 beds to 1,700. Individual facility adverse event totals are included in the report, along with the hospital's number of beds, surgical procedures and patient days. [...]Full text of AMNews content is available to AMA members and paid subscribers.
Copyright 2005 American Medical Association. All rights reserved.
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