Indiana medical errors report released

Governor Mitch Daniels and state health officials Tuesday released the first preliminary report of the Medical Error Reporting System (MERS), designed to provide reliable data on medical errors and improve patient safety. According to preliminary data, 77 medical errors were reported for 2006. Seventy-two events happened at hospitals, and five events occurred at ambulatory surgery centers.

Indiana joins Minnesota as the only other state with a medical error reporting system based on the National Quality Forum serious adverse reportable events. MERS requires hospitals, ambulatory surgery centers, abortion clinics, and birthing centers to report to the Indiana State Department of Health any of 27 serious reportable events in these categories: surgical, products or devices, patient protection, care management, environmental and criminal.

"Any avoidable death or injury is a tragedy, and we want Hoosiers to be the safest citizens in America. Many mistakes are simple to prevent. The data we get from this report will help reduce the frequency of medical errors by revealing causes and identifying statewide trends," said Governor Mitch Daniels.

A 2000 report by the Institute of Medicine suggested that between 44,000 and 98,000 people die each year in U.S. hospitals as a result of medical errors.

State Health Commissioner Judy Monroe, M.D., said as awareness of reporting requirements increases, the number of medical errors in future reports will increase.

"We are requiring health care providers to report errors not to punish them, but instead, to help to improve patient safety," Monroe said. "This kind of transparency will help to create a health care culture that looks beyond blame and supports patient safety through collaboration and responsibility."

According to the report, 23 reported events were stage 3 or 4 pressure ulcers acquired after admission to the facility. Other reported events include:

* Twenty-one events of retention of a foreign object in a patient after surgery.

* Nine events of surgery performed on the wrong body part.

* The remaining 24 events fell in the remaining categories, which can be found in the report on the State Department of Health Web site.

"One patient harmed is one too many," said Kenneth G. Stella, president of the Indiana Health & Hospital Association. "Today's first report on serious adverse events identifies weaknesses in care systems and processes, and it helps set an accelerated agenda for change. Gathering the data is only a first step in the improvement process. Each reporting hospital has studied the causes for the system failures and begun work to prevent their recurrence - not just in their facilities but in every hospital."

"Indiana's new reporting system centers on a basic tenet of health care delivery - preventing harm to patients," said Betsy Lee, director of the Indiana Patient Safety Center. "The system provides a catalyst for greater engagement of all health care stakeholders in the critically important work of redesigning health care processes to protect patients."

"To achieve the best possible patient safety system and one that continuously improves, Hoosiers need a statewide network to identify, understand, and address medical errors," said Joseph Pekny at the Regenstrief Center for Healthcare Engineering at Purdue University. "The Indiana MERS will help provide the data needed to address medical errors in a timely, evidence-based, and effective manner."

Each facility is required to report an 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; distinguishing 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.

Facilities have approximately six months to review and report events, giving them until June 30, 2007. The final report will be issued in August 2007. On Jan. 11, 2005, Governor Daniels issued Executive Order 05-10 requiring the Indiana State Department of Health to develop and implement MERS. The report is available at www.statehealth.in.gov.