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Medical Errors Rise In 2010 Hits 5-Year Peak, State Report Says

THE FORT WAYNE JOURNAL GAZETTE

Parkview's five is in tie for highest

The number of critical medical errors in Indiana hospitals and surgery centers increased last year to 107, the most in the five years state officials have tracked 28 reportable events, according to a study released Monday.

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

The serious errors made in local hospitals in 2010 included surgery performed on the wrong body part and a foreign object left inside a patient after surgery, according to the report by the Indiana State Department of Health.

One category has been broadened from "patient death associated with a fall" to include serious disability associated with a hospital fall. The change could explain some additional cases. A total of 94 events were reported the previous year.

Of the 107 reported errors, 102 happened in hospitals and five occurred in outpatient surgery centers. A total of 295 Indiana hospitals and surgery centers were required to file reports.

The five errors at Parkview Hospital 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.

Lutheran Hospital's two reportable errors were related to serious bedsores.

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

Bedsores, or pressure ulcers, were the most common error, with 34 cases reported in 2010. The second-most common - foreign objects left in surgery patients - was reported 33 times.

Dupont Hospital, which is owned and operated by Lutheran Health Network, reported one case of a foreign object being left inside a surgery patient and one death or serious disability associated with a fall in the hospital at 2520 E. Dupont Road.

St. Joseph Hospital, also owned by Lutheran Health Network, did not report any serious errors.

Parkview Hospital treated the most patients of any health care facility in the region. Parkview discharged 26,725 patients who had been admitted to the hospital and treated 104,549 people on an outpatient basis in 2010. Lutheran Hospital discharged 21,208 patients and treated 71,784 people on an outpatient basis.

"Any event or any error is one too many," said Sue Ehinger, Parkview Hospital's chief operating officer.

After an event, hospital officials investigate to find out why it happened and look for ways to prevent a similar situation from happening again, she said. The investigation typically leads to changes in procedures, Ehinger said.

One of Parkview's biggest problems is with staff members who are hurrying through their duties, she said. Double-checking and triple- checking information often allows staff to prevent mistakes, but hospital officials want to stop short of making procedures overly burdensome.

A trauma patient's life could be at risk if staff insists on quadruple-checking everything, for example, Ehinger said.

Conversations concerning quality care happen daily at the hospital when incoming nurses receive updates on patients' conditions at the beginning of their shifts, Ehinger said.

"We're constantly looking at ways to improve," she said.

Lutheran Health Network spokesman Geoff Thomas on Monday released the following statement in response to Monday's report:

"Lutheran Health Network is dedicated to providing the highest level of quality to our patients, and we regret that anyone has experienced a negative outcome while in our care.

"The Indiana Medical Error Reporting System's annual report continues to be one of multiple resources we use to help our facilities meet or exceed our own high standards for patient care and pinpoint areas for improvement. By using evidence-based best practices and constant monitoring of patient outcomes, our
hospitals are able to identify and understand the cause of an incident so we may quickly implement the changes needed to prevent further errors. These steps are taken months before state data is publicly released.

"Although we believe our ongoing efforts to ensure a safe environment for each and every patient are strong, the best care is still provided by humans and that presents the possibility that errors may occur."

At least one consumer advocate argues that reporting medical errors isn't good enough.

Doug Heller, executive director of Consumer Watchdog, said the Los Angeles-based advocacy group has looked at medical errors for the past 20 years, mostly from a victim's perspective.

Reports, like the one Indiana generates, promote transparency and help patients protect themselves, he said.

"It's better to know than not to know, but it's not enough just to know," Heller said. "What about the person that got hurt? There's a certain heartlessness to statistics."

Indiana's medical malpractice laws make it relatively difficult for victims of medical errors to collect damages. Court cases must first be reviewed by a panel of practicing doctors.

Heller said people who make mistakes should be held accountable.

"These are people and families," he said, "who are suffering because of mistakes."

Contact the author at: sslater@jg.net

AT A GLANCE

Every hospital and outpatient surgery center in Indiana was required to report certain serious errors to the state. Those operating in northeast Indiana, and the number of serious incidents they reported, are:

*Adams Memorial Hospital, 0

*Bluffton Regional Medical Center, 0

*Cameron Memorial Community Hospital, 0

*DeKalb Memorial Hospital, 0

*Dupont Hospital, 2

*Kosciusko Community Hospital, 1

*Lutheran Hospital, 2

*Orthopaedic Hospital of Lutheran Health, 0

*Orthopaedic Hospital at Parkview North, 0

*Parkview Hospital, 5

*Parkview Huntington Hospital, 0

*Parkview Noble Hospital, 0

*Parkview Whitley Hospital, 0

*Rehabilitation Hospital of Fort Wayne, 0

*Select Specialty Hospital - Fort Wayne, 0

*St. Joseph Hospital, 0

*Vibra Hospital of Fort Wayne, 0

*CLI Surgery Center, 1

*Eye Surgical Center of Fort Wayne, 0

*Fort Wayne Cardiology, 0

*Fort Wayne Endoscopy Center, 0

*Grossnickle Eye Center, 0

*Inverness Surgery Center, 0

*Neurospine/Pain Surgery Center, 0

*Premier Surgery Center, 0

*Southwest Surgical Suites, 0

*The Surgery Center, 0

*Surgery Center of Ophthalmology, 0

*Surgery One, 0

Source: Indiana State Department of Health

BY THE NUMBERS

Indiana hospitals and outpatient surgery centers reported providing the following care in 2010:

799,794 - Patients discharged after staying at least one night

3,891,637 - Outpatient visits to hospitals

1,270,063 - Surgical procedures performed at hospitals, including procedures on
patients who didn't spend the night

490,663 - Surgical procedures performed at outpatient surgery centers

Source: Indiana State Department of Health