Medical error problem getting worse, report claims
Study finds annual mortality rate nearly twice of previous estimates
An average of 195,000 people in the United States died from potentially preventable medical errors in each of the years 2000, 2001, and 2002, a new study from the health care quality company HealthGrades Inc. estimates. This puts the annual death toll at nearly twice the rate indicated by previous studies.
A landmark 1999 Institute of Medicine (IOM) report, To Err is Human: Building a Safer Health System, placed the number of annual deaths at around 98,000, and was criticized by many at the time for overstating the problem.
The HealthGrades report used a similar methodology to the one employed by the IOM researchers; however, they examined more patient records, says Samantha Collier, MD, vice president of medical affairs for the Lakewood, CO-based company. It collects quality data from hospitals and provides ratings, information, and advisory services to health care providers, employers, health plans, and insurance companies.
"The HealthGrades study shows that the IOM report may have underestimated the number of deaths caused by medical errors, and moreover, that there is little evidence that patient safety has improved in the last five years," she reports. "The equivalent of 390 jumbo jets full of people are dying each year due to likely preventable, in-hospital medical errors, making this one of the leading killers in the U.S."
The "HealthGrades Patient Safety in American Hospitals" study is the first to look at the mortality and economic impact of medical errors and injuries that occurred during Medicare hospital admissions nationwide from 2000 to 2002. The HealthGrades study applied the mortality and economic impact models developed by researchers Chunliu Zhan and Marlene R. Miller in a research study published in the Journal of the American Medical Association (JAMA) in October 2003.1 The Zhan, et al. study supported the IOM’s 1999 report conclusion, which found medical errors caused up to 98,000 deaths annually and should be considered a national epidemic.
The IOM study extrapolated national findings based on data from three states, and the Zhan and Miller study looked at 7.5 million patient records from 28 states over one year. The HealthGrades study took a more extensive approach by looking at three years of Medicare data in all 50 states and D.C., Collier says. This Medicare population represented approximately 45% of all U.S. hospital admissions (excluding obstetric patients) from 2000 to 2002. The HealthGrades study finds nearly double the number of deaths from medical errors found by the IOM report with an associated cost of more than $6 billion per year.
HealthGrades examined 16 of the 20 patient-safety indicators defined by the Agency for Healthcare Research and Quality ranging from bedsores to postoperative sepsis, but omitting four obstetrics-related incidents not represented in the Medicare data used in the study. Of these 16, the mortality associated with two — failure to rescue and death in low-risk hospital admissions — accounted for the majority of deaths that were associated with these patient safety incidents.
These two categories of patients were not evaluated in the IOM or JAMA analyses, which explain the variation in the number of annual deaths attributable to medical errors.
Some critics charge that the last two categories, particularly the "failure-to-rescue" category, are too vaguely defined and that these patient deaths cannot be said to be automatically attributable to preventable error, says Lawrence Kadish, MD, executive vice president and chief medical officer for White Plains (NY) Hospital.
"Failure to rescue — what does that mean?" he points out. "No one knows exactly what it means. Failure to rescue is not a disease and it is hard to categorize."
That’s not to say, however, that the findings are not credible and that they should not be taken seriously, Kadish emphasizes.
The HealthGrades report examined data since the release of both the IOM report and the subsequent JAMA analysis and still found significant problems. That should be the take-home message.
"Clearly, there is an issue because, even if it is not 195,000 and is only 100,000 or 50,000 deaths, it is too many," Kadish says. "These are reports related to medical errors. There is a lot that has to be done. I think the general awareness in the last five years is tremendously improved. Most hospitals have put numerous safety measures in place, and the Joint Commission has developed its National Patient Safety Goals that are now a part of its accreditation process. But clearly, there is more that needs to be done."
The HealthGrades study was released on July 27 and a copy is available on the company’s web site at: www.healthgrades.com. The report’s key findings include the following:
- About 1.14 million patient safety incidents occurred among the 37 million hospitalizations in the Medicare population during 2000-2002.
- Of the total 323,993 deaths among Medicare patients in those years who developed one or more patient safety incidents, 263,864, or 81%, of these deaths were directly attributable to the incidents.
- One in every four Medicare patients who were hospitalized from 2000 to 2002 and experienced a patient safety incident died.
- The 16 patient safety incidents accounted for $8.54 billion in excess inpatient costs to the Medicare system over the three years studied. Extrapolated to the entire United States, an extra $19 billion was spent, and more than 575,000 preventable deaths occurred from 2000 to 2002.
- Patient safety incidents with the highest rates per 1,000 hospitalizations were failure to rescue, decubitus ulcer, and postoperative sepsis, which accounted for almost 60% of all patient safety incidents that occurred.
- Overall, the best performing hospitals (those that had the lowest overall patient safety incident rates of all hospitals studied, defined as the top 7.5% of all hospitals studied) had five fewer deaths per 1000 hospitalizations compared to the bottom 10th percentile of hospitals. This significant mortality difference is attributable to fewer patient safety incidents at the best performing hospitals.
- Fewer patient safety incidents in the best performing hospitals resulted in a lower cost of $740,337 per 1,000 hospitalizations as compared to the bottom 10th percentile of hospitals.
If the Centers for Disease Control and Prevention’s annual list of leading causes of death in the United States included medical errors, it would show up as No. 6 — ahead of diabetes, pneumonia, Alzheimer’s disease, and renal disease, reports Collier.
"If we could focus our efforts on just four key areas — failure to rescue, bed sores, postoperative sepsis, and postoperative pulmonary embolism — and reduce these incidents by just 20%, we could save 39,000 people from dying every year," she states.
Emphasize accountability, not blame
In addressing the problem of medical errors, it’s important that hospitals address their overall attitudes about mistakes and what cause them, rather than trying to implement foolproof policies that address every type of error, Kadish says.
At White Plains, he makes a point of meeting with new employees in groups to discuss medical errors, emphasizing each person’s potential role in preventing errors.
"I want them to know, if they see a problem — whether they think it’s related to their job or not — that my door is open, and I want to know about it," he explains. "I try to get every employee in the hospital to pay attention to what happens around them as far as safety and their job. If they are employed in housekeeping, then their main safety responsibility is to make sure that the environment is safe, that spills are cleaned up, etc., and we do care about that. But also, if they are walking down the hall and they see an unsafe thing or potentially unsafe thing, my office door is open, come talk to me about it. I want that level of awareness."
That awareness also must be accompanied by assurances that the hospital’s response will be focused on addressing process changes and not by targeting individual employees and assigning blame, Kadish adds.
"We really try to make the point that mistakes are going to happen, You will make a mistake; I’ve made them,’" he says. "What is important is that we go back and try to understand how that mistake happened and implement strategies to keep it from happening again. I try to emphasize that, as medical director and chief medical officer, if a mistake is made, it is ultimately my fault because I did not put in place sufficient policies to prevent it. I tell employees, If you want to blame somebody, blame me. But deciding who to blame helps no one.’"
Many hospitals also focus on system changes such as implementing computerized physician ordering systems to prevent medication errors, or checklist policies to prevent wrong-site surgeries. But, Kadish says, changes to the hospital culture must happen if new systems are to work.
"These are complex systems. Computerized physician order entry is a good example. I think it is a good thing; I think it reduces the number of errors caused by mistakes related to interpreting handwriting, and that is important. But really, it solves one problem and also opens up the potential for other problems," he explains. "How often have you been working at your computer and you have sent the wrong thing or done the wrong thing because you clicked on the wrong button? Instead of handwriting being the issue, there can be 15 different screen choices for dosage, dosing schedule, method of administration, etc. You have to make sure when you hit send’ that you sent the right message to the pharmacy. There is potential for mistakes there, also. You can’t put a system in place and then decide you’ve solved that problem, and forget about it. It’s never that simple."
The HealthGrades report is important, he adds, because it will trigger a re-examination by hospitals of the measures they have taken to address errors.
"We just need to keep the awareness up," he concludes. "This report is good, in that sense, because I read it and immediately started reviewing in my mind some of the things we do here on a day-to-day basis."
1. Zhan C, Miller MR. Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. JAMA 2003; 290:1,868-1,874.
- Samantha Collier, HealthGrades Inc., 44 Union Blvd., Suite 600, Lakewood, CO 80228.
- Lawrence Kadish, White Plains Hospital Center, Davis Avenue and East Post Road, White Plains, NY 10601.