Emphasizing Patient Safety

The Emphasis on Transparency Continues

In March, 2007 Indiana Hospitals took an important step in bringing patient safety issues in Indiana into the open for public examination. The reports Hospitals had submitted to the Indiana State Department of Health (ISDH) during the preceding year were released by the Governor's office via press conference and website. The press carried stories and a general widening of the discussion about patient safety followed. 

All Indiana hospitals are now mandated to report certain kinds of medical errors—the kind that should never occur. For example, if surgery is performed on the wrong body part, that will be reported, and subsequently will be made available to the public. Similarly, there are 26 other serious—but avoidable—medical errors that must be reported, ranging from medication errors to infant abduction.

There is considerable interest in improving “transparency” these days. I think of transparency simply as “the right to know.” Transparency in government—who is spending our money, and for what? Transparency in campaign financing—who is contributing to candidates, and how much? These are things we have a right to know. So it is with medical errors. We all understand that in health care just as in every other facet of life, there are things beyond our control. But what about the things we can control? Are we doing a good job or a bad job at that? That’s what this new reporting system is all about.

On August 20, 2009, ISDH again shared the reports from all hospitals with the public and the media. Elkhart General had two reportable events in 2008, which are described on the following page. As part of our approach to achieving “transparency,” we provide background information about the errors made. This is meant to offer clarity and increase understanding of the steps we take to avoid recurrence.

The reporting system is not designed to point fingers or to be punitive. That is why names of patients and caregivers involved are not given. The purpose is corrective, to make things better, to focus on “how and why” a mistake occurred and to implement procedures that help assure it will never happen again. Blaming or punishing caregivers does not fix systems problems, and it is well established that flawed systems—rather than flawed people—cause most errors.

Reporting medical errors is constructive. It is an action that gives real meaning to the word “transparency.” And it stands to benefit all of us, because all of us—or a loved one—could become a patient at any time.  

Gregory W. Lintjer, FACHE, President and Chief Executive Officer

• Public Release of Medical Errors
  Elkhart General participates in the Indiana State Department of Health (ISDH) Medical Error Reporting Program. This program involves Indiana hospitals reporting specific preventable medical errors to ISDH, which then annually releases all errors in a collective report on their website (www.in.gov/isdh).
• Elkhart General Participates in Five Million Lives Campaign
  Elkhart General has joined the Institute for Healthcare Improvement’s 5 Million Lives Campaign, a national campaign to dramatically reduce incidents of medical harm in U.S. hospitals.
• Summary of Reportable Serious Adverse Events
  All Indiana Hospitals are required to report the following events to the Indiana State Department of Health and indicate the corrective action taken. The state will issue annual reports summarizing the events at each hospital.
• EGH Reportable Adverse Events (2008)
  
• EGH Reportable Adverse Events (2007)
  
• EGH Reportable Adverse Events (2006)
  
• National Awards and Recognition
  
• "Safe Medicine" Consumer Newsletter