Report calls for explicit reporting of deadly medical errors.
When I read that medical errors are the third leading cause of death in the United States, I had no trouble believing it. Human bodies and minds are complex, and caring for them when something goes wrong is difficult.
Sometimes lay people may expect more from the health-care system than it can deliver, but it is also too often true that we get less from it than we should.
My father-in-law was in the hospital recently, and each day something went wrong, but fortunately nothing fatal. He’d just gotten out of the hospital when I saw the report on medical errors from researchers at Johns Hopkins Medicine.
The researchers gathered studies that analyzed documented cases of deaths caused by medical errors, by which they mean an error in judgment, skill or coordination of care, a diagnostic error, a system defect or a failure to rescue a patient from death.
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They estimated 251,454 such deaths occur each year in the United States. Only heart disease and cancer claim more lives. That total doesn’t count deaths of outpatients, or patients who died at home after an error, but only those who died in a health-care facility.
The researchers looked at previous studies that combed through records and put that number together themselves, because those deaths aren’t recorded by the Centers for Disease Control and Prevention as due to medical error. Instead they are listed by whatever condition brought a person to the hospital, such as heart disease.
The researchers from Johns Hopkins, in presenting their estimate, are asking that federal officials change the way those statistics are handled, so that there is a category for deaths caused by errors, whatever the actual number might be.
The team wrote, “Reducing costly medical errors is critical toward the important goal of creating a safer, more reliable health care system. Measuring and understanding the problem is the first step.”
That should hold true for all medical errors, not just fatal ones.
Since 2000, Washington has been one of the states that asks health-care facilities to report “adverse events” (preventable errors) to the government, in this case the state Department of Health. The reports don’t identify patients or staff involved, and there is no link between licensing and the reports.
The purpose is not punishment or establishing legal liability, but to encourage facilities to recognize and correct whatever processes or behaviors contribute to problems. The Johns Hopkins letter to the CDC says that the information it wants the U.S. to collect should be protected from legal discovery to encourage honest reporting.
People make mistakes, and systems designed by people are subject to error. So monitoring and correcting problems should be part of any healthy process, especially when lives are at stake.
My father-in-law spent a week in the hospital last month, and during that time my wife spent long days keeping watch.
A doctor determined at 11 a.m. that he was critically anemic and needed a blood transfusion right away, but they had to find a bed in a partner hospital. He wasn’t in the bed until 7:30 p.m. Nurses paged the doctor on duty, who came at 11:20 p.m., then started the preparations, including ordering blood. The transfusion began around 1 a.m. the next day.
Often new doctors and nurses would start their shifts quickly scanning involved handoff notes, then asking my wife to fill in details. Sometimes the board where the current doctor was supposed to be posted would be out of date.
Once an aide took him to the bathroom, then got busy and forgot to come back for him. The list is longer, but you get the idea.
I’m sure the people delivering care wanted to do their best. Staffers told her there weren’t enough beds, doctors or nurses. Seattle is growing fast, and it’s hard to keep up, but even little things could help, like keeping a checklist of what needs to be done for each patient, so things won’t fall through the cracks.
Better systems help people produce better outcomes, which is all anyone can ask.