Indiana Releases Medical Error Report

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The Indiana State Department of Health today released the annual report of the Indiana Medical Error Reporting System (MERS), which includes reported events for calendar year 2008. The report is designed to provide reliable data on medical errors and improve patient safety. According to the data, 105 events were reported for 2008 with 99 events occurring at hospitals and six events occurring at ambulatory surgery centers.

According to the 2008 report, 33 of the 105 reported events were stage 3 or 4 pressure ulcers acquired after admission to the facility. The other most frequently reported events include:

* 30 events of retention of a foreign object in a patient after surgery; and

* 16 events of surgery performed on the wrong body part.

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In January 2005 Governor Daniels issued an executive order creating the medical error reporting system. This report is the third report issued by the department. The 105 events reported for 2008 compares with 105 reported events in 2007 and 85 reported events in 2006. Pressure ulcers has been the top reported event is all three years.

"The medical error data has been instrumental in increasing awareness of patient safety," said State Health Commissioner Judy Monroe, M.D. "Now that we have identified areas for improvement, the next step is to use this data to focus our efforts on improved quality of care. The state's pressure ulcer initiative is an example of how collaborating on quality results in improved health care quality indicators."

In an effort to address the problem of pressure ulcers, Dr. Monroe says the State Department of Health implemented a 15-month Indiana Pressure Ulcer Initiative to increase focus on the prevention of pressure ulcers. The collaborative initiative began in June 2008 and concludes on August 26, 2009 with an Outcomes Congress in Indianapolis. Participating in the initiative were 95 nursing homes, 40 hospitals, and 28 home health agencies. The initiative focused on improving facility systems through timely assessments, identifying risk factors, and enhancing care coordination. The department expects to announce preliminary results of the prevention efforts at the event.

MERS requires hospitals, ambulatory surgery centers, abortion clinics, and birthing centers to report to the Indiana State Department of Health 27 reportable events in the following categories: surgical, products or devices, patient protection, care management, environmental and criminal.

Each facility is required to report the event, as well as the facility where the event occurred, and the quarter and calendar year of the event. MERS only collects data on the number and category of reported events. It does not collect specific information about the event; distinguish between events that result in death and serious disability; events that result in less than death or serious disability; "near misses;" and root cause analysis.

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