The Indiana State Department of Health reported a decrease in medical adverse events in its medical error annual report.

These events include reported stage 3 or 4 pressure ulcers. According to the annual report, 94 medical error events were reported in 2009, compared with 105 in 2008 and 2007. The current report is the fourth from the department.

The state uses the National Quality Forum's 28 serious reportable events for its system. Serious reportable events are those resulting in death, disability, or surgical events involving a wrong patient, body part, or procedure. The Department of Health's Medical Error Reporting System (MERS) requires medical facilities such as hospitals and ambulatory surgery centers to report adverse medical events in surgery, medical products and devices, patient protection, care, environmental and criminal events. The reporting must include where and when the event occurred.

The report states that 89 of the events in 2009 occurred at hospitals and five in ambulatory surgical centers. Stage 3 or 4 pressure ulcers after admission to a hospital were previously the most reported event, but have now dropped to the second-most reported. The most reported error in 2009 was retention of a foreign object in a patient after surgery. The third most reported was surgery performed on the wrong body part.

According to the Department of Health, the agency began a campaign--the Indiana Pressure Ulcer Initiative--in 2007, and will finish the project in September 2010. The initiative has over 230 health care facilities participating to improve systems. One such project was distributing high-end pressure redistribution mattress and wheelchair cushions for every Indiana nursing home and providing training on the use of the products.

Terry Whitson, assistant commissioner, Health Care Quality and Regulatory Services, Indiana State Department of Health told DOTmed News by e-mail: "Pressure ulcers are a very important health issue. Pressure ulcers are not unique to one type of health care facility or provider. Pressure ulcers can cause pain, infection, damage to muscle or bone, and even death."

Whitson explained that the Indiana Pressure Ulcer Initiative focuses on six essentials of pressure ulcer prevention, including conducting a comprehensive risk assessment upon admission; reassess risk for all patients and residents daily; inspect skin daily; manage moisture; optimize nutrition and hydration; and minimize pressure.

"The positive initiative outcomes demonstrated the importance of health care providers collaborating on quality and providing evidence-based information to caregivers, patients, and families," said Whitson.

The ISDH also developed online education modules on pressure ulcers.

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