Report: Medical errors up in 2014

http://www.news-sentinel.com/living/health/Report–Medical-errors-up-in-2014

In the nine years of reporting medical errors, hospitals and ambulatory surgery centers had more errors than ever before in 2014, according to the ninth annual report of the Indiana State Department of Health’s Indiana Medical Error Reporting System. The report, released Tuesday, indicated 114 reported medical errors in Indiana hospitals and ambulatory surgery centers during the 2014 calendar year — the most since the beginning of reporting medical errors in 2006, the report said. Hospitals accounted for 102 errors, while ambulatory surgery centers reported 12 errors. IU Health hospitals — University, Methodist, Riley and Saxony — of Indianapolis reported the most errors with nine; St. Vincent, Indianapolis, was second with eight; Methodist, Gary, had seven; and Fort Wayne’s Lutheran and South Bend’s Memorial rounded out the top five with five each.

Indiana’s Medical Error Reporting System requires that hospitals, ambulatory surgery centers, abortion clinics and birthing centers report any serious adverse event that occurs within that facility, the report said. In 2014, 287 facilities were required to make reports based on 28 criteria within these categories: surgical, products or devices, patient protection, care management, environmental and criminal. The most reported event for 2014 was stage 3 or 4 pressure ulcers — or bed sores — acquired after admission, followed by retention of a foreign object in a patient after surgery; surgery on the wrong body part; and serious disability or death associated with a fall. These were the same top four reported events in the last seven of nine years of medical-error reporting, according to the report. At Lutheran Hospital, retention of a foreign object in a patient after surgery accounted for two errors; death or serious disability associated with medication error occurred once; and stage 3 or 4 pressure ulcers acquired after admission resulted in two errors. After an error, Lutheran Hospital reviews the incident and works toward improving protocol, according to Geoff Thomas, public relations supervisor at Lutheran Health Network. “Our focus on patient safety and staff education is as strong today as it has ever been,” Thomas said in a prepared statement. “We set the bar high in these areas and regret when we fall short of our own expectations. Personalized, quality care is delivered by humans, and while none of our staff intends to contribute to a medical error, humans can make mistakes. In such instances, we initiate immediate reviews to determine how we can improve for the future. Our network is committed to high-quality patient care delivered in a safe and healing environment.” These Fort Wayne hospitals reported one error: Dupont for retention of a foreign object in a patient after surgery; the Orthopaedic Hospital of Lutheran Health for death or serious disability associated with a fall; and Parkview Regional Medical Center and St. Joseph Hospital for stage 3 or 4 pressure ulcers acquired after admission. Parkview, one of three hospitals that served the highest number of patients in this report, also strives to prevent errors, according to Eric Clabaugh, director of communications at Parkview Health. “One error is one too many,” he said. “We have in place a rigorous process we use to respond to, analyze and understand adverse events in order to prevent these incidents from occurring again. Our response and incident analysis process asks two fundamental questions: why did the event happen, and how can we prevent its recurrence? Patient safety is a daily responsibility for every employee at every Parkview facility, and our patients’ safety is our No. 1 concern while patients are in our care. The foundation of high-quality care begins with the right diagnosis, the right procedure, the right medication at the right time — every time.” The Orthopaedic Hospital at Parkview North, Rehabilitation Hospital of Fort Wayne, Select Specialty Hospital and Vibra Hospital of Fort Wayne reported no errors in 2014. All Indiana ambulatory surgery centers reported at least one error. Out of 3,019 surgical procedures in 2014, Premier Surgery Center experienced one error as the wrong surgical procedure was performed on a patient. The Medical Error Reporting System was created to increase awareness of medical errors by collecting and analyzing data to see where errors occur and how to develop practices to reduce them in the future.

Filed under: General Problems