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November 28, 2011

11/29/11 The Indiana State Department of Health today released its Medical Error Report for 2010.  The annual report is based on the National Quality Forum’s 28 Serious Adverse Events.  The most reported event in 2010 was a stage three or four pressure ulcer acquired after admission to a hospital.  In four out of five years, pressure ulcers have been the most reported event.

There were 107 reported events in 2010.  This is slightly higher than the 105 events reported in 2007 and 2008 and is the most number of reported events in the five-year history of the report.  Some of the increase is attributable to a 2009 change in the falls standard that likely resulted in an increased number of reportable falls events. 

The most reported events in 2010 were:

  • 34 stage 3 or 4 pressure ulcers acquired after admission to the hospital;
  • 33 foreign objects retained in a patient after surgery (30 in hospitals, three in ambulatory surgery centers);
  • 17 falls resulting in a death or serious disability; and,
  • 14 surgeries performed on the wrong body part (12 in hospitals, two in ambulatory surgery centers.

In a positive outcome from previous years, there were no reported medication errors resulting in a death or serious disability.  Previous years reported from three to eight medication error events per year. 

In 2006, Indiana became the second state to adopt the National Quality Forum’s reporting standards.  The reporting standards are not intended as a comprehensive study of medical errors, but rather as representing a broad overview of healthcare issues.  Prevention of medical errors generally requires a system-based approach.  By focusing on a few fundamental prevention activities and an organized prevention system, errors can be prevented. 

An emerging healthcare issue is healthcare associated infections.  The State Health Department recently adopted hospital reporting rules for healthcare associated infections.  Infection reporting will begin Jan. 1, 2012.  Hospitals will report central line associated bloodstream infections, surgical site infections, and catheter associated urinary tract infections.

“The new reporting rules are the result of a recent initiative led by the State Health Department to reduce healthcare associated infections in Indiana,” said State Health Commissioner Gregory Larkin, M.D.  “As the 15-month initiative comes to a close in December, we will continue to evaluate the data and look for meaningful ways to use it in order to protect the health of Hoosiers. I am confident we will see a reduction in healthcare associated infections in Indiana as a result of these new reporting requirements.”

The 2010 Medical Error Report may be found on the Indiana State Department of Health’s website at