NWI Hospitals Report 14 'Never Events' in '06 Study

September 1, 2007
By Mark Taylor Post-Tribune correspondent

Northwest Indiana hospitals accounted for 14 of the 79 medical errors reported by state hospitals in a first-ever report issued by the Indiana State Department of Health.
"The Indiana Medical Error Reporting System (MERS) Final Report for 2006," partly a national trend to improve healthcare quality and patient safety, was mandated by Gov. Mitch Daniels in 2005.

The 54-page MERS report adopted 27 kinds of medical error standards identified by the National Quality Forum and required Indiana hospitals and ambulatory surgery centers to report errors within those categories.

Those so-called "never events" include operating on the wrong body part; performing the wrong surgery on a patient; leaving foreign objects in patients after surgeries; death or disability because of medication errors, contaminated or misused medical devices, drugs or biologics; and severe pressure ulcers (bedsores) acquired after hospital admissions.

Four acute-care hospitals, a surgical hospital and a long-term care "hospitals within a hospital" reported medical errors in Lake, LaPorte and Porter counties.

The number of medical errors is minimal compared to the total number of surgical procedures performed and patients admitted.

Saint Margaret Mercy Healthcare Centers in Hammond reported four errors, all serious bedsores acquired after admission.

Porter hospital in Valparaiso, also reported four errors: two surgeries on the wrong body part and two bedsores.

The Methodist Hospitals in Gary reported a surgery on the wrong body part; a wrong surgical procedure performed on a patient and a death or serious disability related to a contaminated medical device, drug or biologic.

Heartland Hospital, which was then owned by physicians and was acquired recently by the Sisters of St. Francis Health Services, which owns Saint Margaret's, reported a single incident of leaving a foreign object in the body after a surgery, as did Saint Anthony Memorial Health Centers in Michigan City.

Regency Hospital in East Chicago, a long-term acute care hospital within a hospital at St. Catherine Hospital, reported a single incident of a serious bedsore acquired after admission.

Indiana's largest healthcare system, Indianapolis-based Clarian Health, reported the largest number of medical errors, 15, while Fort Wayne-based Parkview Health reported seven errors.

Officials at the Indiana Hospital & Health Association, Methodist Hospitals, Porter hospital and Regency Hospital of Northwest Indiana could not be reached for comment at deadline.

The report was released Friday afternoon on a holiday weekend.

But Gene Diamond, regional president of the Sisters of Saint Francis Health Services, said Saint Margaret's has adopted programs and protocols to prevent future recurrences of bedsores.

"Those incidents did occur and the hospital has put into place a very elaborate mechanism to address and resolve those issues," Diamond said. "Those patients left the hospital in good condition. We quickly corrected those problems and adopted preventive measures."

State Health Commissioner Judy Monroe said the MERS report is a valuable tool to improve patient safety.

"The data we get from this report will help reduce the frequency of medical errors by revealing causes and identifying statewide trends," Monroe said.