State Health Department Releases Medical Error Report

INDIANAPOLIS, IN - The Indiana State Department of Health today released the annual report of the Medical Error Reporting System (MERS), which includes reported events for calendar year 2007.  The report is designed to provide reliable data on medical errors and improve patient safety.  According to the data, 105 medical errors were reported for 2007 with 101 events occurring at hospitals and 4 events occurring at ambulatory surgery centers.

"MERS is a valuable tool to help improve patient safety," said State Health Commissioner Judy Monroe, M.D.  "The data we get from this report will help reduce the frequency of medical errors by promoting awareness of patient safety, revealing causes of medical errors, and identifying statewide trends."

According to the 2007 report, 27 of the 105 reported events were stage 3 or 4 pressure ulcers acquired after admission to the facility.  Other reported events include:

• 24 events of retention of a foreign object in a patient after surgery;
• 23 events of surgery performed on the wrong body part; and
• 31 events fell in the remaining 24 categories, which can be found in the 2007 MERS report on the State Department of Health Web site at: www.statehealth.IN.gov  by clicking on "Medical Errors Reporting System." 

Health officials say pressure ulcers are an example of a system-based problem.  It is not uncommon for a pressure ulcer to develop in one facility and become worse or treated in another facility.  Reducing pressure ulcers requires close care coordination between facilities and frequent thorough care assessments.  Dr. Monroe says the State Department of Health has already taken the following steps to address the pressure ulcer problem:

• Developed and implemented the Indiana Health Care Quality Initiative - Pressure Ulcer Reduction Campaign, an 18-month collaboration among the University of Indianapolis Center for Aging & Community, provider associations and advocacy groups to provide a systems-based approach to reducing pressure ulcers.  The program provides education, training, and technical assistance to 150 health care facilities and agencies on best practices and systems for the prevention of pressure ulcers.
• Provided an alternating pressure, low air loss mattress and four pressure-reducing wheelchair cushions to every nursing home in the state;
• Held a conference in October 2007 for 1167 health care providers with national presenters on pressure ulcer reduction initiatives and experts discussing best practices for ulcer prevention and treatment. 

MERS requires hospitals, ambulatory surgery centers, abortion clinics, and birthing centers to report to the Indiana State Department of Health any of 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.

Source: ISDH Press Release