In January 2005, to increase awareness and create transparency, Indiana Governor Mitchell E. Daniels Jr. issued an executive order requiring the Indiana State Department of Health to develop a medical error reporting system. The Department of Health did so, and began collecting error reports from hospitals, ambulatory outpatient surgical centers, abortion clinics, and birthing centers starting in January 2006.
The goals of the reporting system were to collect and analyze data to reduce future mistakes, to provide information to patients so they can understand their role in reducing errors, to promote the sharing of successful solutions among health care providers, to develop best practices aimed at cutting back on errors, to reduce health care costs, and to promote a culture of open discussion rather than to place blame.
Despite the good intentions, however, it appears that errors in Indiana are still increasing. The final 2010 report just released by the Department of Health revealed that there were 107 reported events in 2010, an increase from the 94 reported in 2009, and the highest number in the five-year history of reporting (although only slightly higher than the 105 errors reported in 2007 and 2008). Pressure ulcers were the most reported event this year (as they were in four of the five years of the report).
There were 34 cases reported in 2010, in spite of a two-year Indiana Pressure Ulcer Initiative program instituted in mid-2008 to address the issue. The second most common error, with 33 reports, was foreign objects left in surgery patients. In 14 cases, surgery was performed on the wrong body part. Death or serious disability associated with a fall was reported 17 times.
Indiana’s medical error reporting system is based on the National Quality Forum’s twenty-eight serious reportable events. A total of 295 health care facilities, the majority of which were hospitals, were required to provide information.