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