1999 mainstream institutions revealed that one of the biggest
killers in the U.S. is medical mistakes.
NEW YORK TIMES reported that 5% of people admitted to hospitals,
or about 1.8 million people per year, in the U.S. pick up an infection
while there. Such infections are called "iatrogenic"
-- meaning "induced by a physician," or, more loosely,
"caused by medical care." Iatrogenic infections are
directly responsible for 20,000 deaths among hospital patients
in the U.S. each year, and they contribute to an additional 70,000
deaths, according to the federal Centers for Disease Control
(CDC). The dollar cost of iatrogenic infections is $4.5 billion,
according to the CDC.
rate of iatrogenic infections has increased 36% in the past 20
years partly because people entering hospitals now are sicker
and more vulnerable then they were 20 years ago, and partly because
excessive use of antibiotics has created antibiotic-resistant
large part of the problem is health care workers who fail to wash
their hands properly, the TIMES reported. "Hands are
the most dangerous thing in the hospital," says Dr. Robert
A. Weinstein, director of infectious diseases for the Cook County
Bureau of Health Services in Chicago. A study conducted at the
Duke University Medical Center found that only 17% of physicians
treating patients in an intensive care unit washed their hands
alternative to hand-washing would be use of latex gloves. Unfortunately,
many health care workers view gloves as protecting themselves
exclusively -- they put them on in the morning and wear them all
day long, the equivalent of not washing their hands. A study of
glove use at a long-term care center found that gloves were worn
82% of the time when their use was indicated, but changed appropriately
only 16% of the time.
have few incentives to monitor infection rates among their patients.
"If you don't do good [infection] surveillance, you don't
detect infections, which means they don't exist and you look great,"
says Dr. William Jarvis, chief of the Investigation and Prevention
branch of the Hospital Infections Program at the CDC in Atlanta.
remedies are being considered. One is to urge health care workers
to wash their hands with waterless, alcohol-based antimicrobial
hand rubs which are as effective as traditional hand-washing but
faster to use and gentler than soap and water.
approach is to train patients to ask each health care worker who
comes into their room, "Did you wash your hands?"
"big picture" of medical mistakes is even worse. A report
entitled, TO ERR IS HUMAN, issued by the National Institute
of Medicine (a division of the National Academy of Sciences) in
November found that medical mistakes kill
somewhere between 44,000 and 98,000 people (average: 71,000) in
hospitals in the U.S. each year.
are about 33.6 million people admitted to hospitals each year
in the U.S. Somewhere between 2.9% and 3.7% (average: 3.3%) of
these suffer an "adverse event" while in the hospital.[2,pg.1]
An "adverse event" is defined as an injury caused by
medical management rather than by the underlying disease or condition
of the patient.[2,pg.25] Of these adverse events,
somewhere between 8.8% and 13.6% (average: 11.2%) are fatal.[2,pg.1]
Of all adverse events, somewhere between 53% and 58% (average:
55.5%) are attributable to mistakes.[2,pg.22]
Therefore we can calculate
that, on average, one out of every 500 people admitted to a hospital
in the U.S. is killed by mistake. (For comparison,
the chance of being killed in a commercial airline accident is
one per 8 million flights.) Thus medical mistakes qualify as a
major public health problem. Even the low estimate, 44,000
killed by medical mistakes each year, exceeds the number of people
killed in the U.S. by automobile accidents (43,458 in 1998).
those who are accustomed to thinking in terms of 1-in-a-million
as an "acceptable" death rate for technological errors,
the 1-in-500 deaths by medical mistakes equates to 2000-in-a-million.
ERR IS HUMAN acknowledges that the 1-in-500 figure may underestimate
the size of the death-by-medical-mistake problem because the 1-in-500
estimate is based on information found in patient records and
many medical mistakes may not be acknowledged in patient records.
TO ERR IS HUMAN says, "Most errors and safety issues go undetected
and unreported, both externally and within health care organizations."[2,pg.37]
"Silence surrounds this issue," the report says.[2,pg.2]
ERR IS HUMAN provides evidence that the 1-in-500 estimate
may be low. The report describes two studies that found rates
of death due to medical mistakes that far exceed 1 in 500. One
study of 815 patients in a university hospital found that 36%
had an iatrogenic illness, defined as "any illness that resulted
from a diagnostic procedure, from any form of therapy, or from
a harmful occurrence that was not a natural consequence of the
patient's disease." Of these 815 patients, 9% had an iatrogenic
illness that threatened life or produced considerable disability,
and for another 2%, iatrogenic illness was believed to contribute
to the patient's death.[2,pg.26] Thus this study
found that 10-in-500, or 1-in-50, patients were killed by a medical
second study looked at 1047 patients admitted to two intensive
care units and one surgical unit in a large teaching hospital.
Of the 1047 people studied, 480 (46%) had an "adverse event"
where an adverse event was defined as "situations in which
an inappropriate decision was made when, at the time, an appropriate
alternative could have been chosen."[2,pg.26]
For 185 patients (18%), the adverse event was serious, producing
disability or death.
important class of medical mistakes is medication errors -- giving
a patient the wrong medication, the wrong dose, or inappropriate
combinations of medications. TO ERR IS HUMAN estimates
that medication errors both inside and outside hospitals killed
7,391 people in the U.S. in 1993, [2,pg.27] but
the report acknowledges that, "Current estimates of the incidence
of medication errors are undoubtedly low because many errors go
undocumented and unreported."[2,pg.29] The
problem seems to be getting worse as doctors prescribe more drugs.
Between 1983 and 1993, hospital patient deaths due to medication
errors increased 2.4-fold while deaths from medication errors
among outpatients increased an astonishing 8-fold.[2,pg.28]
ERR IS HUMAN reports that doctors often do not consider possible
interactions among drugs that they prescribe to a patient. The
report says, "Physicians do not routinely screen for potential
drug interactions, even when medication history information is
readily available." TO ERR IS HUMAN goes on to describe
a study of 424 randomly-selected patients in a hospital emergency
room. Nearly half of these patients (199, or 47%) received new
medications as a result of their hospital visit and in 10% of
those -- 19 individuals, or 4.7% of the study group -- received
medications that added "potential adverse interactions."
"In all cases," TO ERR IS HUMAN reports, "a medication
history was recorded on the patients and available to the physicians."[2,pg.33]
and old people are particularly prone to medication errors, mainly
related to incorrect doses. In one 4-year study of a pediatric
intensive care unit, iatrogenic injury due to a medication error
occurred among 3.1% of 2147 children -- a rate of one iatrogenic
injury among every 33 intensive care admissions.[2,pg.29]
1987 study found that physicians prescribed inappropriate medications
for nearly 25 percent of all older people.[2,pg.33]
physicians are not the only part of this problem. A study of pharmacists
in Massachusetts found that in a year's time 2.4 million prescriptions
(4% of all prescriptions) were improperly filled at the drug store.
Eighty-eight percent of these pharmacist errors involved giving
patients the wrong drug or the wrong strength.
available data about medication errors probably underestimate
the true size of the problem. To ERR IS HUMAN says, "Current
estimates of the incidence [occurrence] of medication errors are
undoubtedly low because many errors go undocumented and unreported."[2,pg.29]
ERR IS HUMAN acknowledges that the true death rate from medical
mistakes may exceed 1-in-500 for other reasons. The 1-in-500 figure
is the in-hospital death rate. "Although many of the available
studies have focused on the hospital setting, medical errors present
a problem in any setting, not just hospitals."[2,pg.2]
And: "...[L]ittle if any research has focused on errors or
adverse events occurring outside of hospital settings, for example,
in ambulatory care clinics, surgicenters, office practices, home
health, or care administered by patients, their family, and friends
at home."[2,pg.25] The death rate from medical
mistakes in nursing homes has not been reported. However, one
study of medications in nursing homes estimated that, for every
dollar spent on prescription drugs, $1.33 is spent treating iatrogenic
injuries and deaths caused by those drugs.
ERR IS HUMAN presents a series of recommendations for improving
medical safety. The stated goal is to reduce deaths from medical
mistakes in hospitals to 1-in-1000 within 5 years. The recommended
way to achieve the goal is to make medical errors expensive: "The
combined goal of the recommendations is for the external environment
to create sufficient pressure to make errors costly to health
care organizations and providers, so they are compelled to take
action to improve safety," the report says.[2,pg.3]
the National Academy of Medicine acknowledges that laudable motives
("First do no harm"), good intentions, years of specialized
training, and voluntary compliance cannot enforce safety protocols.
What works is a hefty monetary penalty.
should all remember this the next time Congress tries to limit
the opportunity for citizens to sue corporations and individuals
who sell unsafe products or services, dangerous chemicals, and
other hazardous technologies. Tort litigation and stiff penalties
provide our best hope of limiting harmful behavior.
Emily Yoffe, "Doctors Are Reminded, 'Wash Up!',"
NEW YORK TIMES November 9, 1999, pg. F-1.
Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, editors,
TO ERR IS HUMAN; BUILDING A SAFER HEALTH SYSTEM (Washington,
D.C.: National Academy Press, 1999). ISBN 0-309-06837-1.
Using data from TO ERR IS HUMAN (pgs. 1 and 22), the average
probability of death by medical mistake after being admitted to
a hospital is: the probability of an "adverse event"
caused by medical management (0.033) multiplied by the probability
that the adverse event will be fatal (0.112) multiplied by the
probability that the adverse event was caused by human error (0.555);
so 0.033 * 0.112 * 0.555 = 0.002 = 1/500. The low death estimate
for hospital deaths is 33.6E6 * 0.029 * 0.088 * 0.53 = 43,700;
the high death estimate is 33.6E6 * 0.037 * 0.136 * 0.58 = 98,000.
We had to make some assumptions to derive the 4% figure. TO
ERR IS HUMAN, pg. 33, says 2.4 million prescriptions were
improperly filled in Massachusetts in a recent year. We do not
know how many total prescriptions are filled in a year in Massachusetts,
but we can estimate the number this way: TO ERR IS HUMAN,
pg. 27, says 2.5 billion prescriptions were filled in the U.S.
in 1998. In 1998, the U.S. population was about 270 million people,
so each person had 9.2 prescriptions filled (average) in 1998.
In 1997, the Massachusetts population was about 2.32% of the U.S.
population, so in 1998 when the U.S. population was 270 million,
the Massachusetts population was probably about 6.3 million people;
if each person had 9.2 prescriptions filled in 1998 then the total
filled in Massachusetts was about 58 million. Therefore 2.4 million
errors represent an error rate of about 4%.
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