Improving Patient Safety: Minnesota Adverse Health Events System

Safety is a priority for everyone, as well as providing and supporting the care of patients. However, health care is complex, and, as a result, there is a risk of errors.  Minnesota created the first in the nation Adverse Health Event reporting system in 2003, using a transparent learning and improvement approach to mitigate and prevent avoidable patient/family harm due to errors resulting from adverse health events. For each adverse event reported, the Stratis Health team supports the facilities’ efforts to prevent the event from occurring again. At the statewide program level, statistical reviews of the program data are conducted to identify trends and create prevention plans proactively.

Actions

• Review and analyze root cause analyses, corrective action plans, and data submitted by hospitals, ambulatory surgical centers, and community behavioral health hospitals.
• Coach and support health care facilities in using evidence-based best practices, tools, and resources
• Advise the Minnesota Department of Health on trends in reported safety events to guide the development of statewide prevention plans.

We make lives better by…

• Implementing evidence-based best practices locally and statewide
• Promoting principles of learning and transparency through public reporting of adverse health events
• Using data from reported adverse health events to uncover and address patient safety improvement opportunities in the state

Contact

Kelly O’Neill
Senior Program Manager
952-853-8507