Adverse Health Events in Minnesota: 15th Annual Public Report.
Approach to Improving Safety
Setting of Care
- Health Care Providers
- Health Care Executives and Administrators
- Non-Health Care Professionals
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2018 report summarizes information about 384 adverse events that were reported and found pressure ulcers and invasive procedure events increased, while fall-related deaths decreased. Reports from previous years are also available.