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Medical Errors Report encourages safety efforts
e-Reports, September 20, 2010
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The battle against bed sores made a difference. Indiana’s Medical Error Reporting System (MERS) showed positive change for 2009.

Reported events

“I’m greatly encouraged by the decrease in stage 3 and 4 pressure ulcers, said State Health Commissioner Gregory Larkin, M.D., upon release of the most recent annual MERS report. “The medical team collaboration to focus on a very serious but preventable health complication well demonstrated the value of consistent application of evidenced-based care.”

The number of pressure ulcers fell to its lowest level in the four years of reporting. At $40,000 per ulcer to heal, the decrease represents a savings of around $440,000.

The pressure ulcer improvement is perhaps linked to the Indiana Pressure Ulcer Initiative that began in June 2008 and concludes this month. Over 230 health care facilities and agencies participated.

“The ISDH’s Pressure Ulcer Initiative and Indiana’s Medical Error Reporting System demonstrate two very positive trends for the care of our patients. The MERS allows citizens to note the improved outcomes,” said Dr. Larkin.

A look at 2009 data
The most reported event for 2009 was retention of a foreign object in a patient after surgery. Retained objects and wrong body part surgeries remained nearly constant from 2008 with no improvement in reported surgical events.

However, in recent years several organizations introduced surgical safety checklists. The Indiana State Department of Health (ISDH) will closely review 2010 data to determine whether checklists result in fewer surgical events. Hospitals and ambulatory surgery centers are encouraged to adopt a standardized checklist and ensure its use.

Also, the recent report showed a decrease, lowest in four years of reporting, in medication errors resulting in death or serious disability. This may partly be the result of increased awareness among providers because of widespread publicity surrounding a few medication error events. The reporting threshold for this event requires reporting only when death or serious disability results, so it may not be statistically significant.

Other notable findings for 2009 include:

  • Reported events decreased from the previous two years.
  • Pressure ulcer events declined to the lowest number in four years of reporting.
  • Number of retained foreign objects replaced pressure ulcers as the most reported event.
  • Medication errors resulting in death or serious disability declined to lowest level in four years.
  • Significant decrease occurred in the number of pressure ulcers in health care facilities.

“The saying ‘if you aren’t keeping score, you’re only practicing’ holds true within our health care system as well,” said Dr. Larkin. “MERS creates an environment whereby recognizing avoidable errors helps identify where improvement is needed and – in the pressure ulcer rate – where improvement has occurred.”

Find the complete MERS report on in.gov.

2009 reported events
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