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– MINNESOTA –
Public and Private Policy
Medical Errors and Patient Safety

Definitions

The State of Minnesota provides definitions for “adverse health care events,” and they are defined to conform precisely with the National Quality Forum (NQF) Serious Reportable Events in Health Care [PDF]. These 27 NQF events are sometimes referred to as the ‘Never Events’ to denote that these are events that are never acceptable outcomes. Minnesota is first state to adopt fully the NQF medical errors reporting standards. This policy initiative is intended to prevent the most serious types of medical errors in hospitals and in outpatient surgical centers. It had broad support from the health care community, including the Minnesota Hospital Association, the Minnesota Medical Association, and the Minnesota Department of Health (MDH).

A list of the events that hospitals and outpatient surgical centers are required to report to the Minnesota Department of Health are available in § 144.7065. However, some of these definitions reference the term serious disability [§ 144.7063.4], which is a key part of many definitions.

(1) a physical or mental impairment that substantially limits one or more of the major life activities of an individual or a loss of bodily function, if the impairment or loss lasts more than seven days or is still present at the time of discharge from an inpatient health care facility, or (2) loss of a body part.

It is noteworthy that the NQF definitions do not include a definition for "serious disability." Among the six states using NQF definitions (CT, IL, MN, OR, NJ, WY), only New Jersey qualifies definitions consistent with the MN "serious disability" interpretation, whereas Oregon discards the term in favor of "serious physical injury."

The reportable events definitions are shown below in the following table.

Minnesota Adverse Health Care Events
Event Type Description of Event
Surgical
Events
1. Wrong Body Part
Surgery performed on the wrong body part
2. Wrong Patient
Surgery performed on the wrong patient
3. Wrong Procedure
Wrong surgical procedure performed
4. Retained Foreign Body
Retention of foreign object in a patient after surgery or another procedure
5. Death of normal, healthy patient
Death of patient with an ASA class I risk during or immediately after surgery (ASA = American Society of Anesthesiology)
Care
Management
Events
1. Medication Error
Death or serious disability associated with a medication error (e.g., an error involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration)
2. ABO-Incompatible Blood or Blood Product
Death or serious disability associated with a hemolytic reaction due to the administration of ABO-incompatible blood or blood product
3. Maternal Labor or delivery
Maternal death, loss of body part, disability, or loss of bodily function lasting more than seven days or still present at discharge associated with labor or delivery in a low- risk pregnancy while in a health care facility
4. Hypoglycemia
Death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is receiving care in a health care facility
5. Neonatal Hyperbilirubinemia
Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in a neonate
6. Hospital-acquired Decubitus Ulcers
Stage III or IV pressure ulcers acquired after admission to a health care facility
7. Spinal Manipulative Therapy
Death or serious disability due to spinal manipulative therapy
Product or
Device
Events
1. Contaminated Drugs, devices, or biologics
Death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the health care facility
2. Unintended use or function of device
Death or serious disability associated with the use or function of a device that is other than the intended use or function
3. Intravascular Air Embolism
Death or serious disability associated with intravascular air embolism that occurs while the patient is receiving care in a health care facility
Environmental
Events
1. Electric shock
Death or serious disability associated with an electric shock while patient is receiving care in a health care facility
2. Patient oxygen or gas line improperly designated
Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances
3. Burn while receiving care
Death or serious disability associated with a burn incurred while patient is receiving care in a health care facility
4. Fall of patient associated with death
Death associated with a fall while patient is receiving care in a health care facility
5. Use or lack of restraints or bedrails
Death or serious disability associated with the use of restraints or bedrails while patient is receiving care in a health care facility
Patient
Protection
Events
1. Infant Discharge to Wrong Person
2. Patient missing over 4 hours
Death or serious disability associated with a patient's disappearance for more than four hours
3. Patient suicide or attempted suicide
Suicide, or attempted suicide resulting in serious disability, while patient is receiving care in a health care facility
Criminal
Events
1. Instance of Care provided by impersonator
any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider
2. Abduction of Patient, any age
Abduction of a patient of any age
3. Sexual Assault of Patient
Sexual assault on a patient within or on the grounds of a health care facility
4. Physical Assault of Patient or Staff
Death or serious injury of a patient or staff member resulting from a physical assault (i.e., battery) within or on the grounds of a health care facility
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