In 2005, Governor Daniels issued an executive order requiring the Indiana State Department of Health (ISDH) to develop a medical error reporting system, and in 2007, the information became publicly available through the ISDH Web site. The ISDH medical error reporting system is designed to make the delivery of care safer and better. The purpose is to focus on ‘How’ and ‘Why’ a medical error occurred, and to help hospitals implement processes to help ensure they don’t happen again.
At Beacon, we strive to create safe systems of care that prevent any harm to patients. This includes using evidence-based practices proven to improve safety. We are also participating in national and statewide safety initiatives such as the national Hospital Improvement Innovation Network. Reporting is an important tool in our safety efforts. Reporting leads to learning, which leads to improved safety.
2016 Results – ISDH Medical Error Report for Beacon Health System
In 2016, Elkhart General reported no errors. Memorial Hospital reported four stage 3 or 4 pressure ulcers.
In honor of full transparency, below is information about these cases and how we addressed our processes to help ensure it doesn’t happen again.
Early in the first quarter of 2016, two patients with extended lengths of stay experienced hospital acquired pressure ulcers. One of these patients was a trauma patient with critical injuries resulting in paralysis. Treating these types of injuries while protecting the patient’s skin is a difficult balance between healing the injury and moving the patient to off load the pressure on bony areas. Unfortunately for this patient, two hospital acquired pressure ulcers developed despite the proactive measures taken. The second patient also had several comorbidities that combined with the long length of stay increased the risk of a pressure injury. The fourth pressure injury involved a patient who was admitted in the 4th quarter of 2016. This patient also had a long length of stay as well as a medical history that contributed to rapid skin breakdown, poor healing and lack of sensation.
Throughout 2016, hospital leaders performed thorough reviews of each of these events. Research of evidence-based best practices related to care of skin and prevention of pressure injuries occurred. As a result, a dedicated, specially trained and certified skin nurse position was created in January of 2017 to focus on the management of skin and pressure injury prevention. In addition, a new process was implemented to review the status of all current pressure injuries at the daily safety huddle, whether the injury was present on arrival or acquired during the stay. This allows hospital leaders to quickly address potential concerns prior to further wound development. These process improvement efforts resulted in a 75% decrease in stage III or IV hospital acquired pressure injuries in 2017.