Four serious medical errors were committed in northeast Indiana last year, twice as many as in 2008, according to a state report released Monday.
In Indiana, 94 errors were reported in 2009, about a 10 percent decline from the previous year.
Lutheran Hospital reported two errors. Parkview LaGrange and Surgery One each reported one. None of them reported a serious error the previous year.
The Indiana Medical Error Reporting System’s fourth annual report collected data on 28 types of reportable events at 306 hospitals and ambulatory surgery centers. The state total fell 11 from 105 reported in 2008 based on 27 types of reportable events at 295 facilities.
Lutheran reported one surgery performed on the wrong body part and one death or serious disability associated with medication error.
Parkview LaGrange reported one Stage 3 or 4 pressure ulcer – or bedsore – that developed after hospital admission.
Surgery One reported one surgery performed on the wrong body part. CEO Ray Kusisto said the case was almost a non-issue because the patient needed surgery on both Achilles’ tendons. The patient had signed paperwork that specified her left foot for the first surgery, but the doctor ended up operating on the right one instead. The second surgery followed two weeks later, as originally planned.
Although the patient wasn’t angry, procedures were altered to ensure the mistake isn’t repeated, Kusisto said.
Betty Brown, Parkview Health’s chief quality and patient safety officer, said the hospital system routinely identifies patients at higher risk of developing bedsores and monitors skin in vulnerable areas, including heels, shoulder blades, buttocks and elbows.
Bedsores can happen when too much weight or pressure is placed on a body part for an extended period. Overweight and paralyzed patients are at higher risk. Part of Parkview’s challenge is to ensure bedsores already present on patients are recorded during the admission process, Brown said.
The number of reported bedsores statewide dropped by 33 percent from the prior year to 22. The improvement follows the creation of statewide initiative to improve risk assessment and care. More than 230 health care providers participate, including Parkview Health.
Asked about its two reported errors, Lutheran Hospital issued a statement reiterating its commitment to patients and providing high-quality health care.
“Despite our best efforts to use systems and processes that help us enhance patient safety, humans are essential to the delivery of patient care, and that presents the possibility that errors may occur. The hospital has worked to identify and understand the cause of each incident submitted for the 2009 report so we can implement changes to prevent further errors,” the statement said, in part.
Lutheran spokesman Geoff Thomas said patient privacy laws prevent hospital officials from providing details of the incidents, including whether one affected patient died or suffered serious disability.
