Frequently Asked Questions: Adverse Events

How do you know everything is being reported?
We believe that all hospitals and surgical centers report their adverse events as soon as they become aware of them. But we check in several ways to make sure:

• MDH staff look at death records every month to see if any deaths were related to adverse events. If it looks like there might be a link, and the event wasn’t reported, we contact the facility to talk about it. If it is a reportable event, the facility has to submit information about it right away.
• MDH or MHA staff contact facilities if we learn about potential events through the media or in other ways.
• Licensing boards, like the Board of Medical Practice and the Board of Nursing, have to report to MDH whenever they learn about an event.
• If a facility doesn’t report an adverse event within 15 days of its discovery, and the event is discovered in another way (such as a patient or family contact or media article), the facility can then be investigated by MDH’s Office of Health Facility Complaints (OHFC). OHFC investigates violations of the VAA or other state or federal requirements, and the results of investigations are public.

What are hospitals doing to prevent events?
Hospitals and surgical centers don’t want these events to happen. They look at each event to find out why it happened.  Then they develop plans to prevent it from happening again. Because of this work, hospitals and surgical centers are changing the way they do things, to keep you safer:

• Developing new ways to count objects used in surgery, and new policies to prevent surgery on the wrong part of the body.
• Using new kinds of equipment or new ways to keep people from falling or getting bedsores.
• Changing policies and procedures to make them consistent across all areas of the hospital and to make sure that they are clearly understood and followed.
• Making sure all staff feel comfortable speaking up about potential problems.

What happens to doctors, nurses or other providers who make mistakes?
Whenever adverse events happen, the doctors and nurses who are involved feel horrible about them. They want to find out what went wrong, so they can prevent it from happening again.
Adverse events usually happen because of a problem with a process or a policy, not because of just one nurse or one doctor. Health care is provided by a team of caregivers. The team has to work together to make sure patients get the safest care.

Sometimes these events happen when a caregiver takes a shortcut. For example, maybe a nurse didn’t want to wake a patient up to check his name before giving him a drug. The nurse didn’t mean to hurt anyone - they assumed that there would be no problems. If that happens, the hospital needs to understand why people take shortcuts, so they can make sure it doesn’t happen again.  If the caregiver was taking risks, the hospital might discipline the person, or train them so they understand the risks of their behavior.

In very rare cases, a doctor or nurse might do something that they know could hurt a patient.  This is very unusual, and very serious.  If that happens, the person might be warned, fired, or put on probation.  The Board of Medical Practice can also discipline doctors if they deliberately put patients at risk.  Other boards deal with nurses, pharmacists, and other caregivers who put their patients at risk.

What should I do with this information?
When you or someone you love is in the hospital, or going in for outpatient surgery, it can be scary. It’s a great idea to do some research before you go to the hospital.

Try to find out about the quality of care at a facility, and about an individual doctor’s experience in treating a condition or performing surgery.  This can give you important information and ease your mind. The information on this website is one piece of the puzzle, but not the only piece.  Other factors might also be important as you make your decision.

But it’s important to remember that this system only includes 28 types of events. It does not include diagnostic or treatment errors outside of those 28 categories. It also doesn’t include bad outcomes that sometimes happen for no reason. The best way to use this information is to use it together with other sources of quality information, such as those you can find on the Patient Safety Links page of this Web site. You can also get important information by talking with your hospital about their quality of care.

What’s a pressure ulcer and how do they happen?
Pressure ulcers are also called bedsores. They happen when an area of skin breaks down due to friction or lack of movement. Most people think pressure ulcers happen over a long time, when someone is bedridden.  But they can happen very quickly if a person is unable to move all or part of their body. In some cases, pressure ulcers can even develop in a few hours, during a long surgery.

People who are older or who have fragile skin, incontinence, or certain chronic diseases that affect the circulation have the most risk for pressure ulcers. Pressure ulcers start as red areas, and sometimes turn into blisters. Finally, pressure ulcers become open wounds. They most often occur on the heels, hips, back, head, or other areas where the skin is very close to the bone.

What is a retained object?
A retained object is something that is left in a patient’s body after surgery, delivery of a baby, or another procedure. Small sponges are the most common retained objects.

Sometimes, retained objects are discovered right away, before the person leaves the operating room. Other times, they are found later, if a patient has pain or problems healing.

Usually, there is no lasting harm to the patient from a retained object. Often, the object can be removed right away, without another surgery. Sometimes, a surgical cut needs to be opened again to take the object out. Some small objects might be left in the body if they won’t cause health problems.

Why don’t you publish doctors’ names?
Under this law, we cannot collect information about the doctors, nurses, or patients who were involved in each event. This system was designed to focus on learning. We analyze every event to see what can be learned from it, and then share that information so we can make everyone safer. The system also holds hospitals and other facilities accountable. Their names and the number of events are published every year, for everyone to see and ask about.

Individual doctors or nurses are still held accountable for their behaviors and their choices, as they have always been. This happens within the facility where they work. Usually, though, these events happen because of a problem in a complicated process, not because of just one nurse or doctor. That’s why this reporting system focuses on what we can learn from why events happened, so we can keep them from happening again.

What should I do if I’m concerned about my doctor or another provider?
The adverse health event reporting system focuses on helping caregivers learn from reportable events and prevent them from happening again. MDH does not collect information about individual providers under this system.

But if you have concerns about your doctor, you can talk with someone at the place where the doctor works, like a doctor, nurse, or patient representative. You can also call the Minnesota Board of Medical Practice. The Boards of Nursing, Pharmacy, and Chiropractic, along with other professional boards, also take complaints or concerns from consumers about providers. Some boards also publicly release information about disciplinary actions taken against providers.

Why are the numbers going up?
Numbers often go up after a reporting system starts. There are a few reasons for this:

• In the past, if someone made a mistake, they might hide it because they thought they would get in trouble. Of if they knew about an unsafe situation, they might stay quiet so they wouldn’t get blamed.  Now people speak up about problems, so we learn about more of them.
• Some of the definitions have changed in the last five years, so hospitals and surgical centers have to report a wider range of events now than before.
• People understand the law better, so they know what they have to report.
• We’re looking harder for these events, so we can learn from them.  If you look more, you find more.

What are the odds an adverse event will happen to me?
These events are very, very rare. There are over 2 million visits to hospitals or surgical centers each year. In the last year, about 300 events were reported, and many of them caused no harm to the patient. So the odds of an adverse event happening to you are very small.
Even though the odds of something happening to you are very small, this is still a very important issue to know about. You should think about this information when you or a loved one are seeking healthcare. Adverse events shouldn’t happen, and if they happen to you or someone you love, it can be very upsetting. Patients and family members need to ask questions about their care, and about what their providers are doing to keep them safe. You can use this information to help you think of those questions.

How are events defined? What’s a “serious” event?
These events are called serious reportable events. The list of events was developed by a national group called the National Quality Forum (NQF). It defines 28 serious events that should never happen. The list of 29 reportable events includes objects that are left in a patient’s body after surgery or an invasive procedure, medication errors or falls that lead to serious disability or death, and surgery on the wrong person or body part.

The definition of "serious" in the NQF list isn't always based on harm to the patient. Some events, like pressure ulcers or retained objects after surgery, might not result in any long-term harm to a patient. But others might lead to death, serious injury, or a longer stay in the hospital. We call these events "serious" because they are signs of larger systems problems.

What can I do to keep an adverse event from happening to me or to a family member?
The people who are taking care of you are responsible for providing high quality care. If an error happens to you while you are in the hospital, it’s not your fault. It is your caregivers' job to make sure that they do everything they can to keep you safe. But there are some things you can do, to make sure that you receive the best possible care:

• Ask questions.
• Make sure that you understand what is going to happen to you while you are in the hospital, and after you go home. Repeat instructions back to your doctor, nurse, or pharmacist to make sure you understand.
• Keep track of your medications. List all of the prescription and non-prescription medications you take.
• If you have concerns about your care, speak up. If you feel more comfortable having a friend or family member speak up for you, bring them along.
• If you are having surgery, choose a facility or doctor who has done the surgery many times.  Ask about the outcomes for previous patients.
• Make sure that your surgical site is marked, and that you and your surgeon agree about your surgery.
• Ask your doctor or hospital about what they are doing to make sure that adverse events don’t happen.

How can a wrong-site surgery or retained object happen? Aren’t there checks in place?
All hospitals and surgical centers have policies in place to make sure that these events don’t happen. They should also follow best practices related to surgery.

For example, if you’ve had surgery, you were probably asked many times to say your name and the surgery you were having, and your surgical site should have been marked before surgery. These are all important steps to prevent wrong-site surgeries. Other steps that you might not see are designed to prevent retained objects.

But sometimes the adverse event still happens. If you’ve ever had surgery, you know that there are usually many people involved – receptionists, assistants, nurses, doctors, anesthesiologists, and technicians you might not even see. Often, adverse events happen because there’s been a communication problem, a policy that wasn’t fully followed or understood, or a difference in how different people understand policies. Sometimes, several small mistakes can happen – any one of them, alone, might not be enough to cause an adverse event, but they happen to line up in just the wrong way, allowing the event to reach the patient.

Are other states doing this?
Yes. Minnesota was the first state to create a mandatory reporting system based on the list of 28 Serious Reportable Events.  But now, about 27 states have some kind of reporting system.