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Indiana Medical Errors Report for 2011

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News Release from the Indiana State Department of Health (Mon Nov 19 2012)

SURGERY ERROR DECREASES

INDIANAPOLIS—Reports of retention of a foreign object after surgery decreased in the past year, according the 2011 Medical Errors Report released today by the Indiana State Department of Health. Seventeen incidents of retention of a foreign object following surgery were reported in 2011, down from 33 incidents in 2010. The seventeen incidents were the fewest number of foreign object retentions in the six years of the Medical Errors Report. 

Stage three or four pressure ulcers acquired after admission continue to be the most reported error. Pressure ulcers, also known as bedsores, have been the most reported incident in five of the six years the Medical Errors Report has been compiled. In 2011, 41 incidents of pressure ulcers were reported, up from 34 in 2010 and the highest number of incidents in the six years of reporting.

The annual report is based on the National Quality Forum’s 28 Serious Adverse Events. A total of 291 hospitals, ambulatory surgery centers, abortion clinics, and birthing centers were surveyed.

“The Medical Errors Report is a helpful tool in increasing patient safety awareness,” said State Health Commissioner Gregory Larkin, M.D. “By learning about the types of incidents that could potentially occur while in the care of a hospital or ambulatory surgery center, patients and their families can gain a better understanding of how to assist in the prevention of medical errors.”

A total of 100 incidents were reported in 2011, down from 107 reported in 2010. The most reported incidents in 2011 were:

·         41 stage 3 or 4 pressure ulcers acquired after admission to the hospital

·         18 surgeries performed on the wrong body part (15 in hospitals, 3 in ambulatory surgery centers)

·         17 incidents of a foreign objects retained in a patient after surgery (15 in hospitals, 2 in ambulatory surgery centers)

·         12 falls resulting in a death or serious disability

·         3 incidents of death or serious disability associated with a medication error

In 2006, Indiana became the second state to adopt the National Quality Forum’s reporting standards. The reporting standards are not intended as a comprehensive study of medical errors but rather as representing a broad overview of healthcare issues. Prevention of medical errors generally requires a system-based approach. By focusing on a few fundamental prevention activities and an organized prevention system, errors can be prevented. 

The 2011 Medical Errors Report may be found on the State Department of Health website at: www.StateHealth.in.gov.

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