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Mistakes are always easier to correct when there is a full understanding of the process involved. Outcomes improve and methods become more efficient. When lives literally hang in the balance of methods of care, education becomes a life-and-death matter.

A new error- and events-reporting system in Minnesota is forcing hospitals to take a hard look at serious mistakes in the health care system and how to fix them. The St. Paul-based Minnesota Nurses Association (MNA) supports the legislation, which was signed into law effective July 1, 2003. Full implementation of the law began December 6.

According to Susan Stout, RN, a lobbyist for the MNA, the law requires that hospitals report medical errors that are among 27 events “that should never happen.” The National Quality Forum (NQF), a nonprofit organization dedicated to developing health care quality measures, developed the list of “never” events. NQF created the list in response to the 1999 Institute of Medicine report “To Err is Human: Building a Safer Health System.” Among the must-report events: wrong-site surgery, retention of a foreign object in a patient after surgery, death or serious disability associated with medication errors, or a fall or use of restraint.

“Essentially, the new law requires that hospitals have to report these errors to the state,” Stout says. “When they report them, [hospitals] have to do a root cause analysis to study what happened and figure out how their system failed. Then, they have to develop a corrective action plan on how they’re going to make sure that it’s not going to happen again. That gets reported to the commissioner of health and portions become public. Obviously patients’ name and nurses’ names are not public.”

Wrongs righted properly

By having to record the event date, description, root cause analysis, and corrective plans of action, hospitals are more accountable for righting wrongs. And, according to the MHA, the approach focuses on learning what went wrong, not on whom to blame.

“In the past, you’d find out if an error occurred if the parties involved became public — let’s say, if the patient that was harmed hired a lawyer and had a press conference,” Stout says. “But patients had no way of knowing that if they were going to have surgery 85 which hospitals [had serious errors]. What it does, is it helps consumers to see who is making the mistakes and what they are doing to fix them.”

Hospitals have been reporting specific events within 15 days of discovering their occurrence via a Web-based patient safety registry. The Minnesota Department of Health began analyzing the data gathered this month and will later publish an annual report, on the Web and possibly in print, that will release some of the data.

If a hospital fails to report an event, the commissioner of health can sanction the hospital’s license. The public and media will have access to information reported, including the name of the institution and the adverse event.

Transparency makes things clear

The information gleaned from the data is good for patients and hospitals. According to Stout, because hospitals have to report events and do corrective action plans, they are forced to face these errors head on.

Stout says the MNA is behind the legislation for two main reasons. The first is patient safety.

“Clearly, if errors are happening, we need to get to the bottom of them and need to make sure they never happen again,” she says. “The second reason [the MNA endorses the legislation] is that we need to begin to make what happens in health care more transparent to the public.”

Nurses might be involved in the process in several ways. Depending on their involvement in a “never” event, they might be involved in the root-cause analysis and in coming up with a corrective plan.

“85 All the energy is placed on figuring out why the error occurred 85 and making sure it doesn’t happen again, rather than figuring out where to point the finger and whom to blame,” Stout says. “Blame is really not the productive way to handle errors. The productive thing is to make sure they never happen again.”

Minnesota is a pioneer in this type of reporting. It is the first state to use the National Quality Forum 27 events in its adverse reporting system, according to the MHA.

“We, here in Minnesota, are unique in the degree of transparency we’ve put into the system through public reporting of the data. Many state systems for reporting medical errors keep that information very confidential,” says John Manning, communications director at the MHA.

For more information, visit www.mnhospitals.org or call (651) 641-1121 and ask for Julie Apold, registry project manager.

Lisette Hilton is a freelance health care reporter.