Reports of stage three or four pressure ulcers acquired after admission decreased from 41 in 2011 to 30 in ‘12, according to the 2012 Medical Errors Report, recently released by the Indiana State Department of Health.
Pressure ulcers, also known as bed sores, have been the most reported incident in six of the seven years the report has been compiled, including in 2012, and average about 30 incidents a year.
As a result of the 2012 meningitis outbreak which was linked to a compounding pharmacy, incidents of death or serious disability associated with contaminated drugs showed a significant increase in the report.
Seven of those incidents were reported in 2012, all occurring in an ambulatory surgery center.
“Medical errors are serious and preventable,” State Health Commissioner William VanNess II, M.D., said in a press release. “I hope this report serves as a call to action to health care providers around the state to be even more vigilant in their attention to detail when caring for patients.”
The annual report is based on the National Quality Forum’s 28 Serious Adverse Events. Two hundred and eighty-nine hospitals, ambulatory surgery centers, abortion clinics, and birthing centers were surveyed.
A hundred incidents were reported in 2012, the same number reported in 2011. The most reported incidents in 2012 were:
• 30 stage three or four pressure ulcers acquired after admission to the hospital;
• 19 incidents of a foreign object retained in a patient after surgery;
• 15 surgeries performed on the wrong body part; and
• 14 falls resulting in a death or serious disability.
In 2006, Indiana became the second state to adopt the National Quality Forum’s reporting standards.
The reporting standards are not intended as a comprehensive study of medical errors, but rather as representing a broad overview of health care issues. Prevention of medical errors generally requires a system-based approach. By focusing on a few fundamental prevention activities and an organized prevention system, errors can be prevented.
The 2012 Medical Errors Report may be found on the Indiana State Department of Health website at www.StateHealth.in.gov.