News From Terre Haute, Indiana

November 21, 2012

State report shows 4 medical errors at Union Hospital in 2011

Sue Loughlin
The Tribune-Star

TERRE HAUTE — In 2011, Union Hospital performed one medical procedure (an anesthetic injection) on the wrong body part and it had one incident of a foreign object retained in a patient after surgery.

In addition, it reported two cases of Stage 3 or 4 pressure ulcers acquired after admission, according to the 2011 Medical Errors Report released Monday by the Indiana Department of Health.

The hospital implemented additional training to reduce the errors, and so far this year, Union has had only one reportable event, according to Dr. John Bolinger, the hospital’s chief medical officer.

“Obviously, any hospital out there that reports these would rather the number be zero,” he said. “We’re doing the best we can to make patient care better.”

The annual report is based on the National Quality Forum’s 28 “serious reportable events,” which may include events resulting in death or serious disability or any surgical event involving a wrong patient, body part or procedure.

Statewide, a total of 100 incidents were reported last year in hospitals and ambulatory (outpatient) surgery centers, down from 107 in 2010. Ninety-four reportable events occurred at hospitals while six occurred at outpatient surgery centers.   

There were 291 facilities in Indiana required to report, including birthing centers and abortion clinics.

IU Health (University, Methodist and Riley) in Indianapolis reported 14 incidents; Methodist in Gary reported six incidents, St. Vincent in Indianapolis reported six incidents, and Union was fourth on the list of hospitals with four incidents.

To put things in perspective, Union Hospital had more than 27,000 hospital admissions last year and performed 18,000 surgeries, Bolinger said. “To have four events involving that number of patients … we’re talking extremely small numbers.”

That’s not a justification, he said, but it’s better than if Union was a small-volume provider and reporting four events.

He also pointed out there were “no horrendous events” that caused severe harm to patients.

One error was listed in the category “surgery performed on the wrong body part.” But Bolinger clarified that it involved injection of anesthetic agent on the patient’s right side when it should have been the left side. The error was caught before the surgery happened, he said.

“You try to put in place every system you can and procedure to prevent that from happening, but it still comes down to human error,” he said. “We put every system we can in place to try and prevent human errors.”

Union Hospital has strengthened its systems and procedures, and it seems to be working, with just one reportable incident so far this year, he said.

The hospital made a training video related to procedures before surgery, and all surgeons and surgical staff were required to watch it. It also was provided to all physicians on the medical staff.  

  It deals with a “surgical time out,” and now, “No surgery is done at this point without a well-documented, surgical time out,” Bolinger said. Before surgery, the surgical team goes through a checklist, similar to what an airline pilot does before leaving the runway.

The team uses more than one means to identify the patient; it identifies the procedure and ensures it is the one the patient signed a consent for; and everyone on the team must agree which side is correct, left or right.

While most hospitals follow this type of procedure, “Some place a lot more emphasis on it,” Bolinger said. “We’ve gone back and placed as much emphasis on it as we can.”

The hospital has “gone out of its way” to re-educate medical staff, and in particular, those doctors and medical staff involved with surgery, he said.

As far as the one incident of retention of a foreign object in a patient after surgery, Bolinger said he could not disclose details because of potential violation of a law safeguarding patient privacy. He was concerned the patient could be identified.

The patient did require a second surgery to remove the object, he said, but in the end, the patient “had a good outcome,” Bolinger said.

As for the two instances of Stage 3 or 4 pressure ulcers acquired after admission, Bolinger noted that of all the reportable events, pressure ulcers “are one of the most difficult for institutions to eradicate completely.” There are many factors involved with the development of an ulceration, he said.

Sometimes it’s difficult to tell the stage of an ulcer when a patient is admitted.

Also, the sicker and more malnourished the patient, the more likely he or she is to develop ulcerations even with frequent turning, he said. “With some patients, it’s almost impossible to eradicate 100 percent,” he said.

All hospitals are striving to improve their methods and to reduce incidents of pressure ulcers, he said.

When Union built the new hospital, it went to new hospital beds that have specialized mattresses to try to relieve pressure on pressure points.

Also, nurses have extra training in proper positioning and turning of patients. “We’ve taken a lot of measures to try and prevent [pressure ulcers] as best we can,” Bolinger said.

The incidents in the state Medical Errors report are self-reported and it is an honor system, Bolinger said. “We take it very seriously. If there is any question, we report it. We don’t sugarcoat it.”

While it might be easy not to report incidents, if it continued, problems would eventually come to light in a survey or patient complaint, he said. “I think by and large, most hospitals are honest,” he said.

The intent of the survey is to focus on areas that need improvement. “If you’re not honest with yourself, you won’t make the process improve and improve patient care,” Bolinger said.

Terre Haute Regional Hospital had no reportable errors, according to the Medical Errors Report.

 “We are very proud of these results. Patient safety and quality care are the top priorities at Terre Haute Regional Hospital and we work each and every day to ensure the safety of our patients,” said Marsha Ciolli, vice president of quality management, in a prepared statement.

Sue Loughlin can be reached at 812-231-4235 or sue.loughlin@tribstar.com.