# Presentation: 354146

##  The Indiana Medical Error Reporting SystemPH/CCC Workgroup

- Roland Gamache, Ph.D., MBA
- Indiana State Department of Health
- February 2, 2007

## Objectives

- Why is medical error reporting important for patient safety?
- What is Indiana’s intent regarding the implementation of a Medical Errors Reporting system?
- How is this system being implemented?

**Notes:**
Three objectives

Left holes on purpose that the other speakers will address

## Medical Error Facts

- Problems in healthcare
- Medical errors:
- 974,000 patients injured
- 44,000 – 98,000 deaths
- Medication errors:
- 185,000 patients injured
- 7,000 deaths
- 30-40% of healthcare dollars misspent on “overuse, under-use, misuse, duplication, system failures, unnecessary repetition, poor communication, and inefficiency.”

***To Err Is Human: Building a Safer Health System, *****Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, Editors; Committee on Quality of Health Care in America, Institute of Medicine, September 1999**

**Notes:**
From the IOM report

Some of the data in question, the need to look at the processes in a way to make these systems safer is not in question

## Recent IOM Report

- For inpatient hospital care for preventable ADEs, the annual cost is $3.5 billion.

## How Hazardous Is Health Care?

**Source: Berwick, D.M.**

**Notes:**
Perspective

## Medical Errors Background

- Medical errors are among the leading causes of death in the United States and impose an enormous economic cost on families and businesses

**Notes:**
From the IOM report and in the press at the time of the executive order

## Medical Error System Changes

- Only limited attention has been focused on the prevention of medical errors
- More common for errors to be associated with processes and systems than a “bad apple” problem
- The best approach toward the reduction of medical errors is by the review of the healthcare system at all levels in an effort to make it safer

**Notes:**
At the time of the executive order

## Medical Error Reporting Impact

- There is a sound body of evidence that Medical Error Reporting Systems (MERS) have a positive impact on health care delivery
- Healthcare is a decade or more behind other high-risk industries in its attention to ensuring basic safety

## Implementation

- Recognizing this opportunity, Gov Daniels issued Exec. Order 5-10 that directed ISDH to implement a mandatory MERS
- The MERS used the 27 NQF-defined serious adverse events as reportable conditions

**Notes:**
Use MERS, but the rule uses Serious Adverse Events

## Implementation (cont)

- The Serious Adverse Events Reporting System in Indiana began on January 1, 2006
- Patient and healthcare professional identities are to be kept confidential
- The Serious Adverse Events Reporting System is not to be used for punishing any healthcare professional
- Requires all healthcare professionals to report medical errors promptly

**Notes:**
Changed terminology

## MERS Process

- Hospitals must report all MERS data to the State Department of Health
- The State Department of Health will (at least yearly) will make this information available on its website
- The State Department of Health will disseminate medical error data to hospital administrators to aid in the implementation of useful error prevention strategies

## MERS Process (cont)

- 27 conditions are required by Indiana rule to be reported to the MERS
- These conditions are reported by Hospitals and Ambulatory Surgery Centers through a secure website to the Indiana State Department of Health

## Additional Steps

- Additional, voluntary reporting systems will provide an important complement to the mandatory system
- Implementation of safety systems in health care organizations
- Hospitals to share successful solutions and improvements with other hospitals

## Reporting System Update

- Organization reports are viewable on-line but only for that organization (and ISDH)
- Current reports suggest that there will be approximately 100 reports submitted.  This number is what was expected.
- Expect the first aggregate report from the data from this reporting system in early spring of 2007