Patient Safety Suffered During COVID-19, MDH Report Finds 


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, according to a new report from the Minnesota Department of Health (MDH). 

Prior to 2021, the 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 lengths 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. 

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 healthcare 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 subsequent 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.