Adverse Events - MDH

Minnesota's adverse health care event reporting

Stratis Health performs review and analysis of root cause analysis (RCA) and corrective action plans (CAP) documentation submitted to the Minnesota adverse event reporting system by hospitals, ambulatory surgical centers, and community behavioral health hospitals. We review each reported event to assess that the facility submits a sufficient summary of the event, the root cause finding(s), and a corrective action plan that is appropriate and reflective of the finding(s) of the root cause analysis. Additionally, Stratis Health provides individual facility feedback to promote system level improvement and facilitate learning within and across facilities. This work has been conducted under contract with the Minnesota Department of Health (MDH) since 2003.

Stratis Health has expertise in conducting root cause analysis and extensive experience supporting providers' efforts with conducting their own RCAs. We also provide training on root cause analysis.

Minnesota Adverse Health Events Measurement Guide

The guide provides instruction on the components required for adverse event measurement plans submitted to the Patient Safety Registry, including examples of commonly missing elements, and clarification on confusing topics regarding measurement. The guide helps organizations with the process of developing, implementing, and evaluating their measurement strategies. It assists those new to the Minnesota Adverse Health Care Event Reporting Law and its reporting requirements, and serves as a resource for the more experienced safety teams. The guide:

• Outlines the process of setting up and implementing measurement plans, using examples throughout to demonstrate the concepts.
• Incorporates strong points in measurement to strive for, pitfalls to avoid, limitations of choices and other considerations to guide the teams decision making related to measurement.
• Provides guidance on how to evaluate the success of an action plan based on measurement results and where to start looking next when the outcome is not as expected. (28-page PDF)

In conjunction with the release of the Minnesota Adverse Health Events Measurement Guide, Stratis Health and the Minnesota Department of Health provided hospitals and surgical centers with training and hands-on practice in developing and analyzing measurement strategies. Training sessions focused on setting up and implementing measurement plans; identifying strong points in measurement to strive for, pitfalls to avoid, and other considerations to guide decision making; and evaluating the success of an action plan based on measurement results. Following are links to the training session handouts:
Presentation, Exercise 1, Exercise 2.

MDH adverse events The MDH site contains background on Minnesota's Adverse Health Events Reporting Law and information on Minnesota's 28 reportable events for providers, policy makers, and consumers.

Annual reports All of the past adverse events annual reports.

Contact Stratis Health for assistance with your quality improvement and patient safety needs.

If your organization has projects it would like to work on, contact us to discuss how we can work together to support initiatives related to reducing adverse events.