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Informational/Educational Report
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MinnesotaÕs adverse health events: pressure ulcers and the patient safety communityÕs response Denise Nix, RN, MS, CWOCN, Ruth A. Bryant, RN, MS, CWOCN, Bonnie Sue Rolstad, RN, MS, CWOCN, webWOC Nursing Education Program, Minneapolis, MN Objectives.This poster/presentation describes 3 actions taken by the state of Minnesota to decrease the incidence of hospital acquired pressure ulcers. It also explains how the laws in Minnesota can affect pressure ulcer reporting in other states and, finally, it describes initiatives where the State collaborates with WOC Nurses to present educational programs to advance knowledge related to pressure ulcer prevention Purpose/Rationale:.A National Quality Forum (NQF) report, Serious Reportable Events in Healthcare released in 2002 presents a consensus list of 27 events that should never happen or Ònever eventsÓ. Among the never events are stage III and IV pressure ulcers As of July 1, 2003, Minnesota became the first state to sign into law mandatory and public reporting of the NQF list of serious reportable events. Connecticut and New Jersey have since signed similar laws. It is speculated that all states will eventually collect and publicly report data on occurrence of these events Methodology:.The Minnesota Department of Health (MDH) released the first-ever report on preventable adverse events in Minnesota hospitals on Jan. 19, 2005. This report offers unparalleled transparency, including data about individual hospitals. Minnesota hospitals reported 99 adverse health events during the 15-month period covered by the report (July 1, 2003 to Oct. 6, 2004). The second most frequently reported event was stage III and IV pressure ulcers. .Results:.The Minnesota Alliance for Patient Safety (MAPS) and the Minnesota Institute for Clinical Systems Improvement (ICSI) responded with the following actions:..-Formed a subcommittee of Minnesota experts including WOC nurses in order to developed tools to support work on pressure ulcer prevention..-Published protocols, documents and tools online for hospital to use and adapt as needed..-Convened a well attended pressure ulcer summit for hospitals, patient safety managers and other key players that was given by WOC nurses.. National Quality Forum, Serious Reportable Events in Healthcare. Washington DC, 2002 Adverse Health Events in Minnesota. Available at: http://www.mnhospitals.org/inc/data/pdfs/MDH_Report1.pdf. Accessed December 4, 2005. |
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