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EGH Reportable Adverse Events (2007)

The following two adverse events were reported to the Indiana State Department of Health. To put these events in context, there were some 12,340 hospital inpatient visits with an average length of stay of 4.69 days and more than 166,537 outpatient visits recorded at Elkhart General during 2007.

1. Stage 3 or 4 pressure ulcers acquired after admission to the hospital (November, 2007)

Prolonged pressure on an area of skin reduces blood supply to that area and can lead to a pressure ulcer. If not properly cared for, an open sore, or ulcer, may result. During this patient’s stay, a Stage 3 Pressure Ulcer was noticed, with no supporting documentation that the patient had arrived with a pressure ulcer 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: The importance of a thorough skin assessment and documentation upon admission was emphasized with all healthcare staff, 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. Surgery performed on a wrong body part (August, 2007)

Failure to follow standard protocols resulted in the procedure beginning on the wrong side of the patient. An initial incision into the skin was made. The error was quickly identified, the procedure stopped, and the incision safely closed. The procedure was then performed on the correct side with no complications.

The Surgical Site Verification process, including the “Time-Out” process, was not followed, which was a contributing factor to the error. Immediately before any invasive procedure such as surgery, medical teams should always take a formal Time-Out - to double-check important, basic information, including: Is this the right patient? Is this the right procedure? Is this the right site? In this instance, the Time-Out was held too early, while the patient was still being positioned, which made it ineffective.

ACTION: A complete review and discussion of both the Surgical Site Verification process and the Time-Out process was conducted with staff. Changes were made to improve clarity, including emphasizing that all surgeons must personally sign their surgical site. Time-Out surgical audits were conducted over a three-month period to verify that they were being held properly.

In addition, a review of the Time-Out process was conducted in all other procedural areas to ensure broad organizational understanding.