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Hospitals: 5 serious errors in '12

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Local hospitals made five major errors in 2012 that resulted in one patient having surgery he or she wasn’t scheduled for and another leaving the operating room with an object left inside the body.

Since 2006, Indiana requires hospitals, outpatient surgery centers, abortion clinics and birthing centers to report serious, preventable errors such as surgical mistakes or accidents resulting in death or disability. Of 236 hospitals and medical centers statewide, 100 errors were made in 2012.

Local hospitals Franciscan St. Francis Health — Indianapolis and Kindred Hospital Indianapolis South in Greenwood each had two reported errors in 2012, while Community Hospital South had one. Johnson Memorial Hospital in Franklin had no reported errors last year.

One error is too many, health care representatives said. Local hospitals encourage staff to report mistakes and then investigate errors to find out why they occurred and make adjustments to prevent them from happening again.

That information is also shared among hospitals regionally and across the state through patient safety organizations in an effort to reduce errors at all facilities, said Jim Fuller, president of the Indianapolis Coalition for Patient Safety.

The state tracks 27 different errors, which include serious mistakes that should be preventable in all medical facilities, Indiana State Department of Health assistant commissioner Terry Whitson said.

Those errors and incidents include performing surgery on the wrong person, discharging a newborn to the wrong family, performing artificial insemination with the wrong donor sperm or egg, or sexual or physical assault of a patient while at the facility.

For example, a hospital should be always able to prevent leaving an object inside a patient during surgery by making sure all materials are accounted for during a procedure, Whitson said.

But a doctor making an error during a surgery that leads to a patient’s death is a serious result and isn’t something hospitals can predict or prevent, so it’s not tracked, he said.

Other mistakes, such as a patient receiving the wrong medication or the wrong dose, do occur in hospitals but aren’t tracked unless they result in death or disability, Whitson said.

“This was intended to be things that should never happen that are major issues,” he said.

Franciscan St. Francis Health reported two incidents, one of operating on the wrong person and one for operating on the wrong body part. Community Hospital South had one report of leaving an object inside a patient during surgery.

Kindred Hospital Indianapolis South had two reports of patients developing serious pressure ulcers, or bed sores, after being admitted to the facility.

Kindred provides long-term care for patients who spend, on average, about a month at the facility.

Staff make efforts to reduce the occurrence of bed sores, but they are sometimes unavoidable due to patients’ medical conditions, according to a company statement.

The two incidents were reported among more than 600 patients  treated in 2012, according to the statement.

Community Health Network strives to have no errors each year, but when mistakes such as the 2012 incident are made, hospital staff and administrative study the problem and try to learn from it, network vice president for quality resources and risk management Jean Putnam said.

The results of the study are then shared with other hospitals through the regional patient safety coalition, she said.

“All of our improvement efforts lead to learning, and learning is critical to getting better. When we do a root-cause analysis, we break that down and find out where that goes wrong. We share that among our peers, we share that among other hospitals, and we don’t want that to happen to anyone else,” Putnam said.

Indianapolis’ six hospital systems have agreed to be open and share safety information, which can allow one hospital to learn from the mistakes of another, Fuller said.

The Indianapolis coalition is one of 11 regional groups working throughout the state, and each regional organization is then able to share information with the Indiana Hospital Association, which oversees all medical facilities, Fuller said.

“We want to learn from each other and improve as a community. What can we accomplish working together that we might have trouble working on individually? If it can happen one place and it can happen anywhere,” he said.

The Indiana State Department of Health does not issue punishments to hospitals that make errors throughout the year but uses the annual report to raise awareness about medical safety and spur new efforts to improve patient care, Whitson said.

For example, the state health department has worked to raise awareness of bedsores and how to prevent them from forming in an effort to reduce the number of yearly incidents, Whitson said.

Statewide error numbers have remained steady since 2006 at around 100 per year. Although that number didn’t change in 2012, Whitson thinks errors declined overall if you remove one batch of incidents.

A meningitis outbreak last year increased reports of contaminated medicines or equipment that otherwise wouldn’t have occurred, making total incidents closer to 90 in 2012, he said.

Some error categories have decreased from year-to-year, which shows safety programs are leading to improvements, Fuller said. For example, bedsore incidents have declined since 2011 as hospitals have worked to address the category that has the highest number of annual incidents, he said.

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