The Indiana State Department of Health has posted a preliminary report on its Web site that lists the number of times incidents the National Quality Forum says should never happen in healthcare happened at the states 287 hospitals, ambulatory surgery centers, abortion clinics and birthing centers. Using the NQF's list of 27 'never events,' the report includes 2006 data received prior to Feb. 26. A final report isnt expected to be issued until August.
So far, the state has counted 72 never events occurring at hospitals and five occurring at surgery centers. These include 23 cases of Stage 3 or 4 pressure ulcers, which represented one event per 160,000 hospital discharges. There were 21 cases of foreign objects left in patients after surgery or other invasive procedures, or one for every 81,000 procedures. Nine surgeries were reported on the wrong body part, equaling one per 189,000 surgeries.
Instead of expecting these figures to go down in the coming years, the agency warned that reported events are expected to increase as awareness of reporting requirements increases. As evidence, the report cites how Minnesota has two less hospitals than Indiana, but reported more than twice as many Never Events occurring154 to 77during the states last reporting period, Oct. 7, 2005 to Oct. 6, 2006.
The stated goal of the Indiana State Department of Health with this report is to improve healthcare services by focusing on data-driven initiatives to promote the development of evidence-based patient-safety initiatives. The initial data on medical errors reinforces the need for healthcare facilities and providers to collaborate on quality, the report stated.
The development and implementation of the Indiana Medical Error Reporting System was called for in a Jan. 11, 2005, executive order issued by Gov. Mitchell Daniels. The NQF released its Never Event list in 2002.