Adverse Health Events Continue to Rise: State Report

May 30, 2024

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 data released by the Minnesota Department of Health (MDH) on May 30. 

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

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

In addition to seeing an increase in total adverse health events reported, the 2023 data also disclosed a concerning 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. 

Longer patient stays continue to be a trend since the COVID-19 pandemic, the data shows. 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 health event. 

Adjusted patient days during the 2023 reporting period grew to 5.9 million during the 2023 reporting period, up from 5.5 million 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 a 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. 

Similar to previous adverse health 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. 

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