Unsafe Staffing Incidents vs. Adverse Events: Is there a difference?

By Carrie Mortrud, RN

Carrie Mortrud, RN

Carrie Mortrud, RN

Recently, a hospital in Cook, Minnesota held a pizza party on January 11. The facility was celebrating 366 days without a patient fall. While it’s great that no patients have been hurt, it’s a head-shaker why we’re now celebrating when bad things don’t happen. Hospitals seem to all be thinking the same thing when the most recent Adverse Event Report was issued. Traumatic injuries in hospitals aren’t going up, but we’re still not doing enough to halt them completely. Meanwhile, the Minnesota Nurses Association’s nurses are reporting more incidents than ever of patients who didn’t get the care they needed through Concern For Safe Staffing forms (CFSS).

I thought it might be useful to point out the distinction between the concern for safe staffing form that the Minnesota Nurses Association collects and tracks on behalf of its members and their patients and the Minnesota Law which requires hospitals to report serious health care events.

Concern for Safe Staffing forms

The Concern for Safe Staffing form was created by a member group of the Minnesota Nurses Association in the mid ‘90’s in an effort to collect data nurses were reporting regarding unsafe care being delivered because hospitals were not staffing nursing care units and departments appropriately for quality patient care. The form has been revised to collect better, more clear, accurate, real time data regarding the numerous times a day Minnesota hospitals fail to provide the right number and right skill mix of staff to care for patients. Recently, MNA created categories at the request of the Minnesota Department of Health to better understand the forms of which thousands were submitted to the commissioner of health last year at the MNA Day on the Hill. For the first time ever, the forms will be presented in the year-end report divided into categories to better understand what the nurses are reporting the hospitals are failing to provide so that nurses can deliver the care they are ethically and legally bound to do and what care they want to give and what patients should expect.

Adverse Events Reporting System

The Adverse Health Events Reporting Law, passed during the 2003 legislative session and modified again in 2004, provides health care consumers with information on how well hospitals, community behavioral health hospitals, and outpatient surgical centers are doing at preventing adverse events. The law requires that these facilities disclose when any of 29 serious reportable events occur and requires MDH to publish annual reports of the events by facility, along with an analysis of the events, the corrections implemented by facilities and any recommendations for improvement.   The law was modified again in 2009 in the Root Cause Analysis section to require hospitals to consider if staffing was a factor in the cause of the event.  The links below further describe the law and the 29 serious reportable events.

http://www.health.state.mn.us/patientsafety/ae/index.html

http://www.health.state.mn.us/patientsafety/ae/adverse27events.html

http://www.health.state.mn.us/patientsafety/ae/adverse29events.pdf

So, what’s the big deal? If Minnesota already has a law requiring hospitals to track serious events, review them and plan on how to prevent them, why are the nurses tracking patient care too?

It’s simple really, nurses believe that before you get a bed sore that exposes bone, before an instrument gets left in your body during surgery,before you fall getting out of bed alone and break your hip, and, by all means, before you die because of a mistake…

THERE is plenty that can be done to create a safer environment in your local hospital so that you receive the best quality care possible!

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