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EGH Reportable Adverse Events (2006)

The following two adverse events were reported to the Indiana State Department of Health. To put these events in context, some 12,700 inpatient visits with an average length of stay of 4.8 days and more than 166,000 outpatient visits were recorded at Elkhart General for 2006.

1. Stage 3 or 4 pressure ulcers acquired after admission to the hospital (February, 2006)

Constant pressure on an area of skin reduces blood supply to that area and can lead to a pressure sore (bed sore). If not properly cared for, an open sore, or ulcer, may result. On the fourth day of this patient’s stay, a Stage 3 Pressure Ulcer was noticed, with no supporting documentation that the patient had arrived with a bed sore problem. It had to be assumed that the pressure ulcer had been allowed to develop after the patient had been admitted, which would mean that proper preventative care had not been provided.

ACTION: All healthcare staff were reminded about the importance of a thorough skin assessment and documentation upon admission, as well as the importance of notifying the Wound Care Registered Nurse to answer questions and/or provide assistance if a problem is identified.

2. Retention of a foreign object in a patient after surgery (March, 2006)

Sometimes the problem of incontinence (accidental release of urine) is corrected by a surgical procedure called a transvaginal cystourethropexy. This procedure involves reinforcing soft tissues to relieve weakness in the anatomy that can cause leakage. Immediately after the procedure, a thin, 3-inch plastic tube about the diameter of a swizzle stick was found to have been left in place.

ACTION: Another visit to the Operating Room was required and the thin tube was removed the same day without another incision and without further complications. The Operating Room team was reminded of the importance of conducting post-operative counts to make sure all items used in the procedure were accounted for prior to closing the surgical wound, and was further reminded that the thin tubes used for this procedure should also be removed.