The number of reportable adverse health events in Minnesota hospitals, licensed ambulatory surgical centers and community behavioral health hospitals increased for the fourth straight year in 2023, according to the latest adverse health events data issued by the Minnesota Department of Health (MDH) today.

Minnesota’s mandatory adverse health event reporting system requires certain types of facilities to report whenever an adverse health event occurs and to conduct a root cause analysis to identify the causes and contributing factors that led to the event. The system includes 29 often preventable errors that could lead to serious injury or death. The goal of the system is to balance quality improvement with accountability and transparency, while developing opportunities for providers to learn from each other about how to prevent adverse health events.

Prior to 2021, the overall number of events had been stable. However, the total number of reported adverse health events (610) and adverse events that resulted in serious injury (222) both reached new highs in 2023.

“Though adverse health events in these settings continue to be rare relative to overall patient volume, we are troubled by the current trend lines of both the number of adverse events and their severity," said Minnesota Commissioner of Health Dr. Brooke Cunningham. “We remain committed to conducting these types of analyses and advocating for changes in how care is delivered to improve outcomes and ensure patient safety for all Minnesotans.”

The data is featured in a new chartbook format and includes adverse health event reports collected from health care providers from Oct. 7, 2022, to Oct. 6, 2023. The data for 2023 shows that total adverse events rose by 38 compared to 2022 and have now increased by more than 166% since 2019, the last year Minnesota reported a decrease in adverse events.

Total reported adverse health events 2014-2023:

In addition to seeing an increase in total adverse events reported, the 2023 data also disclosed a worrying rise in events that resulted in severe injury – a recorded event that is associated with serious injury or death. After decreasing in 2022, the number of severe injuries or deaths increased in 2023 to an all-time high total of 238 and comprised nearly 40% of all recorded events.

Number of reported severe injury adverse health events 2014-2023:

Longer patient stays continue to be a trend since the COVID-19 pandemic. A portion of the 2023 increase in adverse health events can be attributed to the continued growth in adjusted patient days. Prolonged periods of time in the hospital have been linked to an increased risk of experiencing an adverse event.

Adjusted patient days during the 2023 reporting period grew to 5,900,000 during the 2023 reporting period, up from 5,500,000 in 2022. This increase in lengths of stay may stem from things like increased patient complexity due to delayed care and Minnesota’s aging population.

However, discharge delays due to limited bed availability at the next level of care, which can result from post-acute care workforce challenges, also play an important role and contributed to longer stays. This leads to patients being boarded in emergency departments and other locations within the hospital not otherwise suited for inpatient stays. Additionally, some hospitals reported that workforce shortages pushed them toward prioritizing critical care responsibilities, leaving fewer staff to assist with patient care needs, such as repositioning and mobility.

"We understand there are many factors at play, and the strains on our care delivery system that the COVID-19 pandemic exposed are very real,” said Commissioner Cunningham. “However, the data show that these events have grown significantly over the past five years, and we need to keep working as a state to make progress in preventing these types of harm."

Similar to previous adverse event data reports produced by MDH, pressure ulcers and falls were the most common events reported. Falls drove much of the overall increase and rose more than 21% to 96 reported events in 2023. Lost or damaged biological specimens and retained objects from surgeries were also reported in greater numbers.

Number of reported adverse health events by category 2014-2023:

“Every adverse health event touches the lives of our patients and their families and highlights the challenges in our health care system. These difficulties have been exacerbated by serious financial and workforce deficits in our hospitals and health systems, as well as a significant increase in patient stays," said Dr. Rahul Koranne, president and CEO of the Minnesota Hospital Association. “But the latest reports of these events show providers are even more committed to the surest route to improvement: tracking what goes wrong, learning why it happened and striving to do better.”

MDH is continuing its work to address both hospital-specific and systemic issues that impact safety. To further improve the quality of adverse health event data, MDH and its partners have begun to incorporate new methods of collecting and analyzing data. The robustness of these efforts will become more integral in future reports as MDH further implements Phase II of the Adverse Health Events System Evolution project, which aims to evolve and update the system to better suit the needs of the changing health care environment in Minnesota.

More information, including publications and annual reports, is available on the Minnesota Adverse Events Reporting System website.