TERRE HAUTE —
One Wabash Valley hospital reported a patient fall resulting in death or serious disability, while two other hospitals had incidents involving pressure ulcers, according to the state’s 2012 Medical Errors report.
St. Vincent Clay Hospital reported one incident involving death or serious disability associated with a fall.
Union Hospital reported two incidents of stage three or four pressure ulcers acquired after admission, while Terre Haute Regional Hospital reported one incident of the same nature, according to the report, released Monday by the Indiana Department of Health.
Statewide, 100 incidents were reported in 2012, the same number as in 2011. The most reported incidents in 2012 were:
n 30 stage three or four pressure ulcers acquired after admission to the hospital. That represents a decrease from 2011, when the number of incidents was 41.
n 19 incidents of a foreign object retained in a patient after surgery.
n 15 surgeries performed on the wrong body part.
n 14 falls resulting in a death or serious disability.
Pressure ulcers, also known as bed sores, have been the most-reported incident six of the seven years the report has been compiled, including 2012, and average about 30 incidents a year.
“Medical errors are serious and preventable,” said State Health Commissioner William VanNess II, M.D., in a news 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.”
When contacted, St. Vincent Clay Hospital issued the following statement: “We take medical errors seriously, and one error is too many. When one patient is harmed we are all deeply affected at our health ministry. We continue to provide extensive education and training for associates and physicians to identify and prevent patients who are at high risk for falling.
“In addition, we have invested in equipment that notifies clinical staff when a patient leaves their bed, which allows us to immediately be able to respond and address the patient’s needs. It is our priority to keep patients safe in our facility while providing high quality care.”
In 2012, St. Vincent Clay had 810 inpatient discharges, 20,040 outpatient visits and 2,046 procedures.
Union Hospital reported two incidents involving Stage three or four pressure ulcers after admission.
“We’ve really focused a lot of attention and put a lot of resources into this one area,” said Dr. John Bolinger, Union’s chief medical officer.
Amy Allen, med-surg outcomes specialist, said the hospital has undertaken “a mass amount of education” with nursing staff and patient care assistants to identify pressure ulcers and their stages.
Nursing staff “really need to understand what they are looking at and they need to be able to document that well,” Allen said.
In the admission process, the nurse must document that a pressure ulcer exists so that information is available to the physician the first time the physician sees the patient.
The physician then can work with nursing staff on treatment.
If the physician does not sign a form within 24 hours acknowledging the pressure ulcer existed at admission, “It can end up being a reportable event even though it was present on admission,” Bolinger said.
Union has a wound nurse and wound care center.
Pressure ulcers “are a really difficult problem for patients and hospitals because they can be extremely slow to heal due to lack of circulation, lack of nourishment” and possible infection, Bolinger said.
The main treatment in a hospital “is to try to get the pressure off these so you aren’t lying on that area,” he said. “If the patient is lying on it, that impedes circulation even more.”
He noted that Union has many patients who are very ill when they enter, which means they may stay in the hospital longer and may have multiple problems with multiple organ systems. “That predisposes them” to the potential for pressure ulcers, he said.
In 2012, Union had 16,901 inpatient discharges, 74,297 outpatient visits and 29,636 procedures.
At Terre Haute Regional Hospital, Marsha Ciolli, vice president of quality and risk management, noted, “It was our first reportable event since 2008.” The hospital is proud of that record of no incidents for several years, she said.
“We take patient safety and care very seriously. We have many processes in place to ensure our patients remain safe and are well taken care of,” she said. When a patient is admitted, “We do a complete head to toe assessment” looking at skin integrity.
Regional also has a wound care nurse dedicated to seeing all patients who have any kind of skin breakdown, she said.
Ciolli notes that sometimes a pressure ulcer isn’t because of an error. “A patient may be end-of-life and their body cannot support the healing of a skin breakdown. It continues to break down without fault of anyone,” she said.
She believes this type of incident is different from an error in which surgery is performed on a wrong body part or a foreign object is left in a patient after surgery.
In 2012, Regional had 6,382 inpatient discharges, 29,446 outpatient visits and 12,887 procedures.
The annual report is based on the National Quality Forum’s 28 Serious Adverse Events. A total of 289 hospitals, ambulatory surgery centers, abortion clinics and birthing centers were surveyed.
In 2006, Indiana became the second state to adopt the National Quality Forum’s reporting standards.
The 2012 Medical Errors Report can be found on the Indiana State Department of Health website at www.StateHealth.in.gov
Sue Loughlin can be reached at 812-231-4235 or firstname.lastname@example.org.