Contribute Try STAT+ Today

Recent 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.

advertisement

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.

advertisement

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.

  • I just want to point out that your assertion on age of the person to somehow lessen the effect of an error is invalid. I could see using age if it was a contributing factor in the death, as in the person was old and ready to die and the error just helped them die situation…. but in cases where age doesn’t factor in, an error is an error that could have happened to someone of any age and could happen again to someone of any age. The reason for assessing this data is to stop it from happening again to a person that is statistically average, so the age of the person that the error killed is irrelevant in terms of actual purpose.
    I have been citing this info to people for decades, the numbers have not gone down and the two leading causes of death that top it could both be drastically reduced if America had a real healthcare system that emphasized prevention instead of prescriptions. As it is there is plenty of talk about Healthcare from politicians yet not one word about this from them. I hear talk about the horrors of socialized medicine but no mention of facts about how lacking our current system is right here and now.

  • Let’s add the non-treatment and undertreatment of pain to the catalog of medical errors. Physician obeisance to the war on drugs is a tragic abdication of professional responsibility.

  • Medical care is not health care. MDs are only interested in profit and are “dealers” for the pharmaceutical crime families.

    • This is a very unfortunate response from an even more unfortunate patient. This poor person needs a new doctor!

  • Preventing medical errors is an uphill battle in the United States. According to recent statistics released by the CDC, medical errors surpasses certain cancers as a cause of death in the U.S. Unlike cancer, medical errors are always preventable; therefore, many agencies regulating the practice of medicine make emphasis on the importance of educating professionals on how to effectively prevent errors. That is the case of the Florida board of nursing, which requires all nurses seeking licensure in that state to complete a two hour course on the prevention of medical errors prior their application for licensure is submitted for board review and approval. In addition, to ensure that the course meets their standards, only courses completed using an approved Florida continuing education provider are recognized. National Healthcare Institute (www.nhinstitute.com) is one of the approved providers by the Florida board of nursing offering the course fully online and provides instant certificate as proof of completion which is required per board’s rules. This educational effort can provide a safer environment for the millions of American who seek medical attention each year; thus, reducing the medical errors associated death in the U.S.

    The course link for those interested is:

    celearningnetwork.com

  • Your comment concerning the 95 year old’s death vs. a 17 year old’s death is telling. You are making and assessment regarding the value of life….any life. Yes the 95 year old has lived a long life, but at what level of quality? Maybe his last 2 have been the most rewarding of his long life. Does he deserve the indignity or, in my opinion, immorality, of a societal opinion that his life is worth less? It may be to you, but almost certainly not his loved ones or to him.
    A medical error is a medical error is a medical error…Emphasis should be placed on reducing those errors irrespective of stratification based on age.
    Michael Gallagher

  • In Vanay Prasad’s book “Ending Medical Reversal: Improving Outcomes, Saving Lives” the language of “reversal” is the language of doing things to people with no evidence that the things being done serve the people they are being done to. In certain cases, scientific inquiry leads to trials leads to clinical trials which evidence people being hurt or killed (coinciding with the treatment) and the treatment is reversed.

    Not right away, mind you. It can take years.
    Reversals.

    Right now, there should be a Reversal underway for the mistaken use of stainless steel rather than copper and copper alloys in hospital rooms, ICU’s, door handles, sink handles, etc.

    This trial in the US is among many done in the last ten or so years. The properties of copper have been known since the late 1800s.

    http://www.antimicrobialcopper.org/uk/clinical-trials

    Results from a US clinical trial, funded by the Department of Defense, take this evidence to a new level by evaluating the connection between contamination on frequently touched surfaces and patient acquisition of infections. The published findings1 demonstrate that the use of antimicrobial copper surfaces in intensive care units (ICUs) can reduce the number of healthcare-associated infections (HCAIs) by 58% as compared to patients treated in ICUs with non-copper touch surfaces.

    This is the first time an intervention designed to reduce microbial burden has had a clinical impact on ICU patients.
    *snip*

    Clear evidence.

  • By the same standard there are many medical errors not measured, simply because the patient does not die. Yesterday I took a friend who was in the middle of a severe asthma attack to a doctor. He listened to her chest, talking throughout as he did so, and said: “No wheeze, no asthma”. I had expected him, if anything, to tell her she needed to be in hospital and get an ambulance there right away. She was clearly hypoxic and had no exhalation power. He wouldn’t know because, although she told him about the severity of the attack earlier, he didn’t even check blood oxygen levels OR do a respiratory test. He gave her flu meds and sent her home. Five hours later, after a frenetic taxi ride, patient is admitted to hospital with low blood oxygen, splitting headache, chills. and ongoing serious asthma exacerbation. This doctor’s ears WERE good enough to spot the wheeze.

    Oh, and the first doctor prescribed her a drug that contained paracetamol. And did not warn her not to take any other paracetamol medication with it.

    This is not this person’s first near fatal attack due to doctor negligence. One, who preferred to recommend profitable dermatological treatments, previously omitted to warn her aspirin could be a problem. That attack required a mid night ambulance right and resuscitation in the ER. But she won’t be in those figures because she has been lucky.

    Another friend went to a doctor with a rash on her chest. He prescribed her a medication so strong it’s usually given to patients who have had transplants to stop rejection. Its side effects were horrific, including serious stomach problems, and the fact that it was potentially carcinogenic. When he called her next day to see how she was, he was angry she had held off on taking it. “There’s no risk,” he said. “Then how come you are calling to check?” she asked. Doctors where we live don’t do that. Meanwhile the rash had gone. He seemed annoyed by that too.

    Yes. That won’t be in the figures either. Even though a second doctor had been horrified at prescribing such overkill for a skin rash … it would have worked fast.

    Nor will your figures show the time I felt really bad for six months after an appendectomy. I had depression, weakness, lethargy, all kinds of problems. The surgeon said it was just post-operative stress, prescribed calcium pills, and – unofficially – cracking a bottle of whisky and relaxing to get over the trauma. I had also learned the anaesthetic had not worked as well as it should during my operation, which is why I felt so beaten up. My muscles had tensed every time he cut. After months of this, feeling my complexion was yellower than it should be, I went to another doctor who actually listened to me, did a blood test and confirmed I had poorly managed Hepatitis A, and that possibly I’d had it even during my operation. That won’t be in your figures either. Or I wouldn’t be writing this note. Whisky? To a hepatitis patient?

    I agree that more accurate mapping is required. But don’t be surprised if that does not necessarily work in your favour.

    Or course medical people who read your page are defensive, but with doctors. like every other profession, wise patients never forget that half of them graduated in the bottom half of the class. And when that is combined with a propensity for not listening, or viewing through their own narrow spectacles, it is potentially devastating.

  • Last updated: April 27, 2016

    From CDC

    Leading Causes of Death

    Heart disease: 614,348
    • Cancer: 591,699
    • Chronic lower respiratory diseases: 147,101
    • Accidents (unintentional injuries): 136,053
    • Stroke (cerebrovascular diseases): 133,103
    • Alzheimer’s disease: 93,541
    • Diabetes: 76,488
    • Influenza and pneumonia: 55,227
    • Nephritis, nephrotic syndrome, and nephrosis: 48,146
    • Intentional self-harm (suicide): 42,773
    *snip*

    So Medical Error is not listed as a leading cause of death.
    Why?

    1. People are not told of medical mistakes which have directly impacted their lives – if they are fortunate enough to survive them.

    2. Deaths are reported as from another cause.

  • Based upon the definition of a medical error in the original BMJ article, aren’t ALL deaths due to a medical errors? If your spouse drops dead of a heart attack tomorrow while playing tennis, well then why not blame the medical system for not identifying their heart disease ahead of time? The focus on medical errors with such ludicrous definitions, bloated and sensational statistics and media coverage is asinine and counter production: the next time you encounter the medical system you can be sure your providers, in their attempt to avoid medical errors, will order unnecessary tests and do other things that will only increase the risk of other medical errors.

Comments are closed.