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Medical errors drop at hospitals

Serious bedsores up in ’11; Parkview logs turnaround overall

The number of critical medical errors in Indiana hospitals and surgery centers fell last year to 100, with serious bedsores accounting for 41 of the incidents, according to a study released Monday.

Seven hospitals in northeast Indiana reported one serious medical error each. Parkview Hospital, one of the seven, marked a significant turnaround – dropping to one error from five the previous year.

State officials have tracked 28 reportable events for six years. The number of serious bedsores reported in 2011 is the highest since tracking began.

The 2010 report included 107 critical errors total, including 34 due to “pressure ulcers,” the official term for bedsores.

Bedsores can occur when too much weight or pressure is placed on a body part for an extended period. Vulnerable areas include heels, shoulder blades, buttocks and elbows. Overweight and paralyzed patients are at higher risk.

The ulcers begin with a red mark. At Stage 3, the sore has become an open wound. Stage 4 pressure ulcers are extensively infected, black in color and contain dead tissue. Stage 3 and 4 bedsores that occur after admission to the health care facility must be reported to state authorities.

Lutheran Hospital, St. Joseph Hospital and Adams Memorial Hospital each reported one case of serious bedsores in 2011.

Parkview Hospital and Premier Surgery Center each reported one case of a foreign object being left in a patient after surgery.

At Grossnickle Eye Center, officials reported performing the wrong surgical procedure on one patient.

And at Dupont Hospital, one patient suffered a serious disability or death associated with a fall on hospital property.

The remaining northeast Indiana hospitals and surgery centers disclosed no serious medical errors for last year.

The latest report marks a significant turnaround for Parkview Hospital.

Last year, Parkview Hospital reported five significant events, a tie with a South Bend hospital for the most of any individual hospital in the state during 2010.

Parkview’s five errors included one surgery performed on the wrong body part, one suicide or attempted suicide resulting in serious disability, two cases of serious bedsores and one death or serious disability associated with a fall in the hospital at 2200 Randallia Drive.

On March 17, Parkview staff moved most of the hospital’s patients to the newly constructed Parkview Regional Medical Center, just north of Dupont Road. That facility was not included in the report just released.

Dr. Greg Johnson, Parkview Health’s chief medical officer, is pleased by the amount of improvement his staff made from 2010 to 2011.

But, he said, “one of these events is one too many.”

Parkview’s mantra is “report, learn and fix,” Johnson said. Officials review all patient outcomes to look for ways to improve care. The staff focuses on continuous, daily improvement, he said.

Since late 2010, Parkview officials have made numerous site visits to learn best practices from other hospitals. They included a trip to ThedaCare-owned hospitals in Wisconsin, where Parkview staff learned the collaborative care model.

Since spring 2011, Parkview caregivers have used collaborative care, which involves scheduling a doctor, nurse and case manager to visit patients’ bedside as a group. A pharmacy staff member is included as needed. Making rounds together ensures that the health care providers coordinate care.

Parkview managers and directors also attend quarterly Leadership Development Institute sessions that sometimes review patient outcomes, Johnson said.

The state’s health department stresses that serious medical errors are often the result of a failure in procedures and systems rather than the fault of an individual person. By studying errors, health care officials can create processes that prevent them.

Dr. Johnson agreed. All errors committed by his staff are assessed by Parkview’s Quality Board, which is a subcommittee of the system’s board of directors.

The kinds of errors that cause serious harm always come before the board because they cause significant consequences that are noticed by the patient’s team of caregivers, he said.

As for avoiding bedsores, the most common serious error in this year’s report, Johnson said Parkview’s “incredible nursing care” is the reason.

Lutheran Hospital also improved its performance last year after reporting two incidents of serious bedsores in 2010. The hospital’s 2011 report included one such incident.

Lutheran Health Network spokesman Geoff Thomas said the health care provider is committed to providing quality patient care and regrets any negative outcome.

“We conduct a thorough review of any unexpected outcome to fully understand what happened so we can work to prevent it from happening again,” Thomas said in an email. “Adoption of evidence-based best practices and constant monitoring of patient outcomes are important parts of this process. Our facilities continuously work to provide a safe, healing environment for patients.”

A total of 291 Indiana hospitals, surgery centers and other providers were required to file reports based on care provided last year.

By the numbers

Indiana hospitals and outpatient surgery centers reported providing the following care in 2011: 805,943
Patients discharged after staying at least one night 3,972,170
Outpatient visits to hospitals 1,247,659
Surgical procedures performed at hospitals, including procedures on patients who didn’t spend the night 490,659
Surgical procedures performed at outpatient surgery centers
Source: Indiana State Department of Health

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