A new report from the Minnesota Department of Health shows the number of reportable adverse events and instances of patient harm rose in 2021 during the past year-long reporting period in Minnesota hospitals, ambulatory surgical centers, and community behavioral health hospitals.
Prior to 2021, the overall number of events had been stable, but 2021 saw an increase in events, primarily due to new challenges and increased care associated with the COVID-19 pandemic. Clinicians were forced to adapt in real time as hospitals and health systems took care of sicker, higher acuity patients with multiple health concerns. Increased patient complexity due to COVID-19 led to longer hospital stays and other complications arising from delays in seeking care.
The length of stay in intensive care units more than doubled from 2.31 days in 2017 to 5.47 days in 2021. Longer hospital stays can lead to an increase in skin breakdown (pressure ulcers) by increasing the time a patient is lying down or using a medical device. Patients with longer length of stay may also experience loss of strength, leading to an increased risk of falling. The report and information about individual facilities is available on the Adverse Health Events reports webpage.
"The pandemic tested our health care system and our health care providers in an unprecedented way in 2021," said Minnesota Commissioner of Health Jan Malcolm. "The pandemic also showed the value of our adverse health events reporting system. By having this system, we were able to track the effects of this extraordinary event on patient safety, and we can use these results to work with Minnesota's providers to increase our resiliency and ability to confront future challenges."
Other pandemic-related factors included increased time for staff to put on personal protective equipment before being able to care for a patient and potentially prevent a fall, and higher caseloads.
This adverse health events report provides an analysis of the data collected from health care providers from October 7, 2020, to October 6, 2021. The report shows 508 adverse health events reported during this period, with 207 serious injuries and 14 deaths. Though the number of deaths remained stable, there was a significant increase in the number of events and subsequently injuries compared to 2020. The increases were in categories likely to be impacted by longer stays, namely, falls and pressure ulcers. It is important to note that many event types require a certain level of harm or injury to be reportable under the law.
In 2021, the total number of reported events increased to 508 (up from 382 in 2020). As in years past, pressure ulcers and falls were the most reported events, accounting for 217 or 60 percent of the reportable events, followed by 86 falls, 36 biological specimens, 36 retained objects and 28 wrong site surgeries.
"The global pandemic pressed every patient, family and health care team into extraordinary circumstances," said Dr. Rahul Koranne, president and CEO, Minnesota Hospital Association. "This statewide reporting and learning system affirms Minnesota's hospital and health system culture of transparent reporting and commitment to providing high quality, safe care."