Adverse Health Events in Minnesota: 14th 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 2017 report summarizes information about 341 adverse events that were reported and found that the number of fall-related deaths and wrong-site surgeries increased, while incidents of pressure ulcers decreased. Reports from previous years are also available.