In the newest Indiana Medical Error Report, the total number of errors in hospitals, ambulatory surgery centers, abortion clinics and birthing centers grew by 13: 107 reported in 2010 and 94 in 2009.
Medical errors generally occur not from one person’s mistake but from failures of systems and processes. That means members of the health care community must keep focusing on fundamental prevention activities – organizing systems to reduce or even eliminate medical errors.
“Aviation has taught medicine a great deal about how to analyze events or near-events, and to change systems and processes to decrease the risk of future adverse events,” said ISMA Past President Kevin Burke, M.D., chair of the ISMA’s Quality and Patient Safety Task Force.
Since 2005, Indiana health care facilities have been required to report events as a way to increase awareness of patient safety issues and improve care. The annual statewide report is based on the National Quality Forum’s (NQF) listing of 28 serious adverse events.
In the five years since reporting began, pressure ulcers have been the most persistent problem, and the numbers are up in this category for 2010. However, there is one bright spot. No medication errors resulting in death or serious disability were reported in this most recent year.
The number of falls resulting in death or serious disability was up considerably, from 8 in 2008 and 2009 to 17 in 2010. A change in standards to be more consistent with the NQF likely impacted these numbers, according to the Indiana State Department of Health.
“Valid data is needed to prove trends and show you have decreased the risk of events,” noted Dr. Burke. “We do support expanding our reporting to include infections.”
Find the complete error report on in.gov.