Emphasizing Patient Safety

Bringing Patient Safety into the Open

On his inauguration day in January, 2005, Governor Mitch Daniels took an important step in bringing patient safety issues in Indiana into the sunlight of public scrutiny. He signed an executive order mandating public reporting of “Serious Adverse Events” by all Indiana hospitals. His order was very clear. If surgery is performed on the wrong body part, that information will be reported to Indiana State Department of Health (ISDH), which will make it available to the public. His order required that 26 other Serious Adverse Events be similarly reported, ranging from medication errors to abduction of an infant.

After considerable work by numerous individuals, that order became a reality on March 6, 2007, when ISDH shared the reports from all the hospitals with the public and the media. Elkhart General had two reportable events in 2006, which are described in detail on the following pages.

The reporting is specifically designed not 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 a caregiver will not fix a systems problem, and it is well established that flawed systems—rather than flawed people—cause most errors.

In addition to reporting error information, Indiana hospitals are actively sharing their corrective actions and “best practices.” Many Hospitals, including Elkhart General, are part of the national “5 Million Lives Campaign,” which is explained in a related article.

Where is all this going? It is going toward a new, measurable national standard of care. It is bringing governing bodies, such as hospital boards of directors, into the quality control process to oversee and demand that quality standards be established and met. It is requiring that hospitals and physicians forge ever closer alliances to improve care. In short, it is a very good thing that 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

• 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 (2006)
  
• National Awards and Recognition
  
• "Safe Medicine" Consumer Newsletter