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At a glance
Indiana hospitals and outpatient surgery centers reported the following serious errors in 2012:
30 – Serious bedsores acquired during hospital stay
19 – Foreign objects left in patients after surgery
15 – Surgeries performed on the wrong body parts
14 – Falls that led to death or serious disability
Source: Indiana State Department of Health

Medical errors on decline or stabilizing

Local centers credit new focus, checklists

Indiana hospitals and surgery centers reported 100 serious medical errors last year, the same number as in 2011, officials announced Monday.

In northeast Indiana, only four reportable errors occurred in 2012. The previous year, seven hospitals in the region reported one serious medical error each.

The most recent mistakes fall into two categories.

A foreign object was left in a surgery patient at Lutheran Hospital. Surgery was performed on the wrong body part at Orthopaedic Hospital of Lutheran Health and at Parkview Huntington Hospital.

Because of incorrect information provided to The Journal Gazette, the print edition story and earlier online versions of this story carried incorrect information about a local surgery center. That information has been removed from the stories.

Because of patient privacy laws, local health care providers won’t provide details of what happened in any individual case.

The most common mistake statewide led to 30 patients getting bedsores so severe that the pressure ulcers became open wounds and possibly turned black, became extensively infected and contained dead tissue.

The number is a 37 percent decrease from the prior year, when 41 serious bedsores were reported, including three in northeast Indiana. That was the highest total in the report’s seven-year history.

State health care providers in 2009 launched a statewide initiative to improve bedsore risk assessment and care.

The sores develop when too much weight or pressure is placed on a body part for an extended period. Vulnerable areas include heels, shoulder blades, buttocks and elbows. Overweight and paralyzed patients are at higher risk.

Bedsores – also called pressure ulcers – become reportable errors only if they develop after admission to a health care center and they progress to Stage 3 or 4. That’s when they become open wounds.

The 2012 Medical Errors Report included data from 289 hospitals, ambulatory surgery centers, abortion clinics and birthing centers. The facilities were required to report errors in 28 categories established by the National Quality Forum, a nonprofit, nonpartisan, public service organization that reviews, endorses and recommends use of standardized health care performance measures.

Indiana adopted the reporting standards in 2006. Since then, the state has averaged 99.4 reportable events per year.

The latest report includes seven deaths or serious disabilities related to the 2012 meningitis outbreak triggered by contaminated drugs distributed by a Massachusetts compounding pharmacy.

Officials with the Indiana State Department of Health stress that the report is meant to guide improvement efforts rather than spread blame.

“Medical errors generally are not the sole result of actions of individuals but rather the failure of the systems and processes used in providing health care,” the report’s executive summary states. “The requirement to report events identifies persistent problems, encourages increased awareness of patient safety issues and assists in the development of evidence-based initiatives to improve patient safety.”

Judy Boerger, Parkview Health’s senior vice president and chief nursing executive, said safety is top of mind for employees, who rely on checklists to ensure they take every necessary step during various procedures.

Parkview officials also encourage staff members to stay focused when working with patients and double-check steps when appropriate.

“It’s really a daily approach to patient safety,” Boerger said. “It is truly a team effort.”

As hospital processes evolve, Parkview staff is proactive by looking for where failure is possible and avoiding it, she said.

“There is always an opportunity for improvement,” she said.

Lutheran Health also looks for ways to provide better, safer care to patients.

Geoff Thomas, spokesman, sent the following statement by email:

“We regret any medical error and work immediately to identify its root cause and learn from it. Opportunities to improve are addressed and acted upon,” he wrote. “Our network is committed to high-quality patient care delivered in a safe and healing environment. These objectives are accomplished through adherence to best practices and ongoing staff education.”

sslater@jg.net

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