INDIANAPOLIS — At first glance, a state report on medical errors in Indiana hospitals, released this week, seemed like good news: The number of reportable incidents was down last year from previous years.

But that’s not the whole story.

According to a national expert in patient safety, the 2009 Indiana Medical Error Report contains “very little relationship to reality” because of the information that’s missing: thousands of medical mistakes that likely occurred in hospitals across the state but weren’t reportable by law.

“You can’t say medical errors are going down,” said Dr. William Tierney, the incoming president and CEO of the Regenstrief Institute, a health care research organization affiliated with Indiana University School of Medicine.

An official with the agency that issued the report agrees, in part. Terry Whitson, assistant commissioner of the Indiana State Department of Health, said the state’s Medical Error Reporting System may be misnamed. Rather than all medical errors, the state only requires hospitals to report errors that result in death or serious disability or any surgical event involving a wrong patient, body part or procedure.

Absent from the report, because it’s not required, are the less damaging errors and the “near misses” — errors caught they occur. Also missing: the number of hospital-acquired infections that may lead to extended stays, additional treatment or even death.

Because of that, only 94 preventable medical errors were reported by the 309 medical facilities that performed more than 1 million procedures last year.

“There are more medical errors that occur in every one of those hospitals than what all of them reported for the entire year,” said Tierney, an internist who regularly sees and treats patients.

Said Whitson: “This is not an inclusive report of all medical errors.”  

There are no inclusive reports, though there are national studies that suggest the extent of medical errors. Ten years ago, the Institute of Medicine released a study that estimated that up to 98,000 patients were dying each year as the result of preventable medical errors. It’s a number still quoted by patient-safety advocates.

Meanwhile, the Centers for Disease Control and Prevention estimates there are 1.7 million hospital infections and 99,000 associated deaths each year. Other studies show one in seven hospitalized Medicare patients experiences one or more medical errors with adverse events, and one in 15 hospitalized children is harmed by medication errors.

Indiana was on the forefront when it instituted the reporting system in 2005 as a catalyst for hospitals to institute safety systems much like in the aviation industry with its pre-flight checklists designed to reduce human error. The state adopted reporting standards recommended by the National Quality Forum, a coalition of health care providers. The NQF established the 28 reportable medical errors as “never events” — preventable medical errors that should never occur if good patient-safety systems are in place.

The NQF, though, is moving to expand the scope of reportable incidents. “This was just the first level of reporting,” Whitson said. “They’re working on a second generation of medical error reports that will dig much deeper and add more standards.”

The current reporting system has already brought about some change, said Betsy Lee, director of the Indiana Patient Safety Center. The public disclosure has prompted many hospitals throughout the state to institute standardized safety systems, including checklists before surgical procedures and color-coded wristbands on patients that signal drug allergies or other special concerns.

“The state’s Medical Errors Report has been a catalyst for change,” said Lee. “It’s created an important conversation about safety.”

Among the changes that have come about: An increasing number of Indiana hospitals are adopting standards for how body parts are marked before surgery. “In some hospitals, an X meant ‘cut here,’” said Tierney. “In other hospitals, it meant ‘don’t cut here.’ That didn’t change until we started talking to each other about patient safety.”

Tierney likes to quote a Japanese saying: Every error is a treasure. “That means that every error uncovered is valuable,” Tierney said, “because it allows us to improve the processes that caused the error.”

Maureen Hayden is Statehouse bureau chief for CNHI’s Indiana newspapers. She can be reached at maureen.hayden@indianamediagroup.com.