Patient Safety, 2006

The State of Minnesota

June 2006

The State of Minnesota used the AHRQ Patient Safety Network (http://psnet.ahrq.gov) and the AHRQ WebM&M (http://webmm.ahrq.gov) to assist in the development and implementation of Minnesota's Adverse Health Events Reporting Law. Minnesota is the first state in the nation to institute a mandatory adverse health event reporting system as recommended by the Institute of Medicine report, To Err is Human.

"We have used AHRQ products to inform our work on the Adverse Health Events Reporting Law. We find the AHRQ WebM&M case studies and analysts' commentary to be very helpful, particularly when similar events are reported in our system. These cases are also helpful for general guidance on how to approach certain types of events," says Diane Rydrych, Assistant Director of the Office of Health Policy, Statistics and Informatics, at the Minnesota Department of Health (MDH).

Passed in 2003 and fully implemented in 2004, Minnesota's Adverse Health Events Reporting Law requires hospitals and ambulatory surgical centers to report 27 types of "never events"—events that are serious, largely preventable, and of concern to both the public and healthcare providers—as well as the subsequent findings of root-cause analyses and the corrective action plan. The MDH is then charged with tracking adverse events, analyzing corrective action plans, studying trends, and disseminating information about best preventive practices across the state.

Annually, MDH publishes a public report of the adverse events and the corrective actions at each hospital and ambulatory surgical center in Minnesota. The 2006 Annual Report detailed 106 adverse events. Published in February 2006, the Annual Report included AHRQ's Consumer Web page (http://www.ahrq.gov/consumer) as a resource to support consumers in making informed decisions about health care safety and quality.

Impact Case Study Identifier: CQuiPS 06-10
AHRQ Product(s): WebM&M, Patient Safety Network (PSNet)
Topic(s): Patient Safety
Scope: Minnesota

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