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#682 - Medical Mistakes, 12-Jan-2000

During 1999 mainstream institutions revealed that one of the
biggest killers in the U.S. is medical mistakes.

** The 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.[1] 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.

The rate of iatrogenic infections has increased 36% in the past
20 years[1] 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 killer microbes.

** A 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
appropriately.[1]

An 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.

Hospitals 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.[1]

Various 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.

Another approach is to train patients to ask each health care
worker who comes into their room, "Did you wash your hands?"

* * *

The "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.[2]

There 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[3]
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).

For 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.

TO 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]

TO 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 mistake.

A 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.

An 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]

TO 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]

Children 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]

A 1987 study found that physicians prescribed inappropriate
medications for nearly 25 percent of all older people.[2,pg.33]

And 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.[4]

Lastly, 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]

TO 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.

To 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]

Thus 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.

We 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.

--Peter Montague (National Writers Union, UAW Local 1981/AFL-CIO)

=====

[1] Emily Yoffe, "Doctors Are Reminded, 'Wash Up!'," NEW YORK
TIMES November 9, 1999, pg. F-1.

[2] 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.

[3] 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.

[4] 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%.

Descriptor terms: medical mistakes; mortality statistics;
morbidity statistics; hospitals; infections;