Statement issued Monday:
The Indiana State Department of Health today released the Indiana Medical Error Reporting System (MERS) annual report, which shows a significant decrease in the number of reported stage 3 or 4 pressure ulcers (commonly known as “bed sores”). Ninety-four medical error events were reported in 2009, compared to 105 reported each year in 2008 and 2007.
“I am greatly encouraged by the decrease in stage 3 and 4 pressure ulcers,” said State Health Commissioner Gregory Larkin, M.D. “The medical error data has been instrumental in increasing awareness of patient safety.
"The purpose of the Medical Error Reporting System is to identify areas for improvement and then use that data to focus our efforts on improving quality of care for Hoosiers. MERS identified pressure ulcers as a problem, so we launched the Indiana Pressure Ulcer Initiative. The decrease in the number of pressure ulcers is likely linked to that initiative.”
The Indiana Pressure Ulcer Initiative began in June 2008 and concludes in September 2010. More than 230 health care facilities and agencies participated in the Initiative. The initiative focused on improving facility systems through timely assessments, identifying risk factors, and enhancing care coordination.
Other highlights from the 2009 report follow:
- Of the 94 reported events, 89 occurred at hospitals and 5 occurred at ambulatory surgery centers;
- 29 of the 94 reported events were retention of a foreign object in a patient after surgery;
- 22 events of stage 3 or 4 pressure ulcers acquired after admission to the facility; and
- 17 events of surgery performed on the wrong body part.
The 2009 MERS Report may be found on the State Department of Health Web site at: www.statehealth.IN.gov by clicking on “Medical Errors Reporting System.”
MERS requires hospitals, ambulatory surgery centers, abortion clinics, and birthing centers to report to the Indiana State Department of Health 28 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