ecent headlines telling us that medical errors are now the third leading cause of death deliver as much “news” as headlines telling us that Bill Clinton was the 42nd president of the United States. While the report in the BMJ — and the press release promoting it — sounded like researchers were on to something new, they were merely reminding us of old data.
To get their estimate that medical errors cause 251,454 deaths a year among hospitalized patients in the United States, the authors essentially averaged error-related death rates from four prior studies and then extrapolated it to the number of hospitalized patients today. There is nothing bad about that, but there’s nothing tremendously innovative about it, either. If the researchers had really wanted to update the estimate for the modern age, they should have dug into patient records and made tough decisions about which deaths were truly due to errors — in other words, they should have done their own analysis.
Defining ‘medical error’
Here is one elephant in the room in this area of research: What is a medical error? The authors of the BMJ report define it as any action “that does not achieve its intended outcome” or any planned action that, for whatever reason, is not done “that may or may not cause harm to the patient.” This definition is uselessly broad. It is like dividing the world into the United States and all other countries, then engaging in diplomacy. Here’s a definition I think would be fair: A medical error is something a provider did or did not do that caused a bad outcome (death in this case) and — this is a big “and” — the action should have been done differently given what was known, or should have been known, at the time.
By any decent definition, some errors are obvious, such as when a doctor or nurse gives a patient a wrong and deadly dose of a drug. But many “errors” exist in a gray zone. Say a doctor delays sending a patient to the intensive care unit and she later dies. Would she have died had she been transferred to the ICU 45 minutes sooner?
When it comes to suspected errors, those who think they can always pinpoint which actions led to potentially preventable harm are either kidding themselves or are incredibly arrogant. One of the most difficult things about medicine is that much of the time we don’t know for sure if an outcome would have been different had we acted another way. Good doctors agonize about this.
Not all deaths are equal
There’s another problem. The BMJ article, and the subsequent reporting about it, continue a trend where the public is wrongly told that all deaths are the same. They aren’t.
When it comes to determining the impact of death, we intuitively understand that a 95-year-old dying of a medical error, while regrettable, is not as tragic as a 17-year-old dying from one. The 95-year-old had lived a full life, while the teenager missed out on so much. Most analyses treat each error-related death as the same. A better statistic to use would be years of life lost. It corrects for the fact that some deaths are more untimely than others.
This doesn’t mean that any error is ignorable — it isn’t. But it means we ought to weigh medical errors fairly.
Don’t sacrifice accuracy
The new estimate of 251,454 deaths matters because the sensational figure is imprecise and may be wrong by a large magnitude. The renewed attention on medical errors in hospitals might be good, prompting doctors to take it more seriously. But it could be harmful if it scares some people away from getting the care they need. It could also lead overzealous, out-of-touch hospital managers into constructing painful bureaucratic solutions to the problem of medical errors that ultimately don’t help. That happens. We are still living under one such regimen that doesn’t work — the universal use of gloves and gowns for all patient contact to prevent the spread of antibiotic-resistant bacteria in hospitals.
Communicating scientific information isn’t easy. It’s natural to want to make journal articles and media reports sound interesting. But that shouldn’t sacrifice accuracy. Here’s how I would summarize the BMJ report: The authors made a number of reasonable proposals so we can better understand medical errors, which probably happen often but honestly aren’t something we have a good definition for and don’t do a good job of measuring or tracking.
But you won’t get any great headlines out of that.
Vinay Prasad, MD, is assistant professor of medicine and senior scholar in the Center for Ethics in Health Care at Oregon Health & Science University, and coauthor (with Dr. Adam Cifu) of Ending Medical Reversal: Improving Outcomes, Saving Lives.