State Health Department Addresses Pressure Ulcers

INDIANAPOLIS, IN - The Indiana State Department of Health today hosted a conference in Indianapolis for health care providers to address the problem of pressure ulcers (bed sores).  According to the 2006 Medical Errors Reporting System (MERS) report, 26 of the 85 reported events were stage 3 or 4 pressure ulcers acquired after admission to the facility. 

Health officials say pressure ulcers are an example of a system-based problem and that it is not uncommon for a pressure ulcer to develop in one facility and become worse or be treated in another facility. 

"The purpose of today's conference is bring together representatives of all parts of the health care system, including hospitals and nursing homes, to start a dialogue on how the system can be improved to prevent pressure ulcers," said State Health Commissioner Judy Monroe, M.D.  "Thanks to the Medical Errors Reporting System, we were able to identify pressure ulcers as a leading cause of medical errors in Indiana and can now better address the problem. 

"The purpose of MERS is not to place blame for errors, but instead, to improve patient safety through collaboration and responsibility," said Dr. Monroe.  "That is exactly what today's conference is all about - identifying problems and finding solutions."

To help prevent pressure ulcers in nursing homes, the Indiana State Department of Health is contracting with Hill-Rom to provide an alternating pressure, low air loss-mattress to every nursing home in the state.  Each nursing home will receive one mattress.  The State Department of Health is also contracting with EHOB to provide pressure-reducing wheelchair cushions to every nursing home in the state, with each facility receiving four cushions.  Both Hill-Rom and EHOB are Indiana-based manufacturers and are leaders in the development of pressure-reducing devices.

"Most nursing homes rent these mattresses as needed for their residents, but often there is a 24- to 48-hour wait before the mattresses can be delivered," said Terry Whitson, assistant commissioner, Health Care Regulatory Commission at the State Department of Health.  "By providing each nursing home with one of these mattresses, we hope to prevent this kind of delay and allow residents at risk for pressure ulcers to have immediate access to the care they need."

Today's conference included national presenters on pressure ulcer reduction initiatives and experts discussed best practices for ulcer prevention and treatment.  Representatives from all Indiana hospitals, nursing homes, patient care organizations, and state health surveyors were invited to attend.  The conference will serve as a kick-off for additional state initiatives for the prevention of pressure ulcers.

In January 2005, Governor Daniels issued an executive order requiring the creation of a Medical Errors Reporting System.  MERS requires hospitals, ambulatory surgery centers, abortion clinics, and birthing centers to report to the Indiana State Department of Health any of 27 serious reportable events in the following categories: surgical, products or devices, patient protection, care management, environmental and criminal.   The Indiana State Department of Health released the 2006 MERS report in August 2007.  The final report reflects all reported events for 2006 and is available on the State Department of Health Web site at: http://www.statehealth.in.gov/.    

Source: Indiana State Department of Health