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Medical Error
2001-Present
Reducing and Preventing Adverse Drug Events To Decrease Hospital Costs
"Adverse drug events (ADEs) result in more than 770,000 injuries and deaths each year and cost up to $5.6 million per hospital, depending on size. Many ADE injuries and resulting hospital costs can be reduced if hospitals make changes to their systems for preventing and detecting ADEs. Some approaches found to be successful are summarized...".
Research in Action, Issue 1. AHRQ Publication Number 01-0020, March 2001. Agency for Healthcare Research and Quality.
Making clinical trials safer for human subject.
"In our national endeavor to hasten the development of new biotechnology products for improving healthcare, we have created a vast enterprise of clinical trials in which experimentation on thousands of human subjects is performed without sufficient regard for their safety and without reasonable prospects for their therapeutic benefit."
Michael Baram, American Journal of Law & Medicine, Summer-Fall, 2001
Adverse events in British hospitals: preliminary retrospective record review
"110 (10.8%) patients experienced an adverse event, with an overall rate of adverse events of 11.7% when multiple adverse events were included. About half of these events were judged preventable with ordinary standards of care. A third of adverse events led to moderate or greater disability or death."
Vincent et al., BMJ 2001;322:517-519 (3 March)
Medical errors: a common problem
"Errors are problems that will not go away. A pilot study by the Royal College of Physicians into deaths after admission for medical emergencies suggests that some error occurred in as many as one in five cases, although not necessarily leading to an adverse event (unpublished). These data should be interpreted cautiously but do suggest that actual recorded adverse events are the tip of the iceberg."
K G M M Alberti president, Royal College of Physicians of London, BMJ 2001;322:501-502 (3 March)
Current Research on Patient Safety in the United States (pdf)
"This report and the database define the current landscape of patient safety and medical error research in the United States, identify a sample of key organizations that support patient safety-related research, explore the current and future directions and barriers to conducting this type of research, and present a searchable database of active research projects identified by the surveyed organizations."
Cooper JB, Sorensen AV, Anderson SM, Zipperer LA, Blum LN, Blim JF; Health Systems Research, Inc. subcontract # 290-95-2000. National Patient Safety Foundation, 2001.
H. pylori: The Key to Cure for Most Ulcer Patients
While physicians are widely overprescribing antibiotics, many of them are not prescribing the drugs when they are called for, as in the treatment of ulcers. Are they not properly educated, incompetent, or just unwilling to change established habits, even when those habits lead to suffering and death?
"After the NIH recommendations were published, national surveys of primary care physicians and gastroenterologists indicated that approximately 90% of these physicians correctly identified H. pylori infection as the primary cause of ulcers. However, primary care physicians still reported treating more than 50% of their first time ulcer patients with acid-reducing medications and not antibiotic-based regimens. Even gastroenterologists reported treating over 30% of their patients with first time ulcer symptoms with acid-reducing medications alone."
Benjamin D. Gold, MD, Centers for Disease Control and Prevention, 2001
See also:
The Helicobactor Foundation
Helicobacter pylori and Ulcers: a Paradigm Revised, Nancy A. Lynch, FASEB.
Smug as a bug. "He was so sure he was right and conventional medical wisdom wrong about the cause of stomach ulcers that he swallowed bacteria to prove his point. Now once-sceptical peers are talking about a possible Nobel prize." Sydney Morning Herald, Aug 2, 1977.
Adverse drug events in emergency department patients
"ADEs [adverse drug events] encompassed an important segment of ED encounters and annual health care costs. ED screening may provide useful information about the epidemiology of outpatient ADEs."
Haffner et al. Ann Emerg Med 2002 Mar;39(3):258-67
A national point-prevalence survey of pediatric intensive care unit-acquired infections in the United States
"There were 512 patients in 35 PICUs. The median age was 2.2 years. Seventy-five PICU-acquired infections occurred among 61 (11.9%) patients ... This national multicenter study documented the high prevalence of PICU-acquired infections. Preventing these infections should be a national priority.
Grohskopf et al., J Pediatr 2002;140:432-8
Causes of prescribing errors in hospital inpatients: a prospective study
"Our results suggest that most mistakes were made because of slips in attention, or because prescribers did not apply relevant rules. Doctors identified many risk factors--work environment, workload, whether or not they were prescribing for their own patient, communication within their team, physical and mental well-being, and lack of knowledge. Organisational factors were also identified, and included inadequate training, low perceived importance of prescribing, a hierarchical medical team, and an absence of self-awareness of errors."
Dean et al. Lancet. 2002 Apr 20; 9315; 359
The Reliability of Medical Record Review for Estimating Adverse Event Rates
Three separate doctors reviewed each medical record according to the same set of instructions. The researchers then calculated how frequent mistakes were among the 500 patient records using different definitions.The estimated number of mistakes ranged from fewer than 1% (1 in 100) to more than 32% (32 in 100), depending on the rules set by the researchers. (Journal summary of article.)
Thomas et al., Ann Intern Med. 2002;136:812-816.
The Wrong Patient
"Among all types of medical errors, cases in which the wrong patient undergoes an invasive procedure are sufficiently distressing to warrant special attention. Nevertheless, institutions underreport such procedures, and the medical literature contains no discussions about them. This article examines the case of a patient who was mistakenly  taken for another patient's invasive electrophysiology procedure. After reviewing the case and the results of the institution's "root-cause analysis," the discussants discovered at least 17 distinct errors, no single one of which could have caused this adverse event by itself. The discussants illustrate how these specific "active" errors interacted with a few underlying "latent conditions" (system weaknesses) to cause harm. The most remediable of these were absent or misused protocols for patient identification and informed consent, systematically faulty exchange of information among caregivers, and poorly functioning teams."
Chassin MR and Becher EC, Ann Intern Med. 2002;136:826-833.
Misdiagnosis of Hereditary Amyloidosis as AL (Primary) Amyloidosis
In this study, about 10 percent of people with hereditary amyloidosis were misdiagnosed and improperly treated.
Lachmann et al., N Engl J Med 346:1786-1791
Are selective COX 2 inhibitors superior to traditional non steroidal anti-inflammatory drugs?
Based on a study widely known to be flawed, physicians are prescribing $3 billion of Celebrex each year.
Juni et al., BMJ 2002;324:1287-1288 (Editorial)
Doctor Prescribes Quality Control for Medicine's Ills
When Ann Berwick was hospitalized in 1999 with symptoms of a rare autoimmune disorder of the spinal cord, she fell victim to many of the flaws in the U.S. health-care system...Mrs. Berwick was scheduled for immediate treatment with a crucial drug. But even though she was gravely ill, she didn't get the first dose for 60 hours...Again and again, as new doctors got involved in the case, they repeated orders for other drugs that had already been tried unsuccessfully. Hospital staff gathered Mrs. Berwick's vital data, such as blood counts, body temperature and weight, in a disorganized way. And, on three occasions, they left her frightened and alone on a gurney late at night in a hospital subbasement..."Nothing I could do ... made any difference," recalls her husband, Donald Berwick, a Harvard-trained physician. "It nearly drove me mad."
Bernard Wysocki jr, The Wall Street Journal, May 30, 2002.
Patient safety: what about the patient?
 "Plans for improving safety in medical care often ignore the patient's perspective. The active role of patients in their care should be recognised and encouraged. Patients have a key role to play in helping to reach an accurate diagnosis, in deciding about appropriate treatment, in choosing an experienced and safe provider, in ensuring that treatment is appropriately administered, monitored and adhered to, and in identifying adverse events and taking appropriate action. They may experience considerable psychological trauma both as a result of an adverse outcome and through the way the incident is managed. If a medical injury occurs it is important to listen to the patient and/or the family, acknowledge the damage, give an honest and open explanation and an apology, ask about emotional trauma and anxieties about future treatment, and provide practical and financial help quickly."
D.A. Vincent and A. Coulter. Qual Saf Health Care 2002;11:76-80
Barriers to incident reporting in a healthcare system
"The findings of this study suggest that healthcare professionals, particularly doctors, are reluctant to report adverse events to a superior...The culture of medicine—with its emphasis on professional autonomy, collegiality, and self-regulation—is unlikely to foster the reporting of mistakes. Moreover, the organisational culture of the NHS (UK), with its emphasis on blame, and an increasingly litigious public may only serve to exacerbate the problem. Research in the USA suggests that, although errors in medicine are common and can lead to significant patient injuries, there are legal impediments to adopting the kind of error reduction strategies that have proved successful in other industries. The reporting of errors is crucial to the process of error management, but physicians with tort liability concerns may be reluctant or unwilling to do so, given legal rules which grant the plaintiff's attorney access to this information. Together, the culture of the medical profession which discourages reporting and increasing fears of litigation are therefore likely to constrain the reporting of errors in the NHS."
R.. Lawton and D. Parker, Qual Saf Health Care 2002;11:15-18
Mammogram Team Learns From Its Errors
 "Seven years ago, Dr. Kim A. Adcock started a revolution in mammography: He decided to keep score...Dr. Adcock had just become radiology chief at Kaiser Permanente Colorado, and he was already hearing whispers of problems with his staff. So he pored over the doctors' records, counted the cancers they had missed and printed their batting averages in bar charts and graphs...This was deeply controversial territory. To many doctors, keeping score was yet another assault on their autonomy and prestige. It could also, they warned, be dangerous: The statistics were tricky and easily twisted. The malpractice lawyers would pounce. Worse still, if women knew how many cancers their doctors had missed, they might avoid mammograms altogether."
Michael Moss, The New York Times, June 28, 2002
Tonsillectomy and Adenotonsillectomy for Recurrent Throat Infection in Moderately Affected Children
 "The modest benefit conferred by tonsillectomy or adenotonsillectomy in children moderately affected with recurrent throat infection seems not to justify the inherent risks, morbidity, and cost of the operations. We conclude that, under ordinary circumstances, neither eligibility criteria such as those used for the present trials nor the criterion for surgery in current official guidelines are sufficiently stringent for use in clinical practice."
Paradise et al., Pediatrics 2002;110:7-15
Chicago Tribune special report: Unhealthy Hospitals (site requires free sign-up)
Infection epidemic carves deadly path
"A hidden epidemic of life-threatening infections is contaminating America's hospitals, needlessly killing tens of thousands of patients each year." 21 July 2002
Lax procedures put infants at high risk
"The Tribune linked the deaths of 2,610 infants in 2000 to preventable hospital-acquired infections. Examining patients of all ages, the Tribune identified 75,000 preventable deaths where hospital-acquired infections played a major role. This analysis, based on the most recent national data, is the most comprehensive of its kind and draws on thousands of hospital and government inspection reports." 21 July 2002
Infection epidemic carves deadly path
"Over several weeks starting in October 1998, 31 children contracted flulike infections and eight died as the microscopic invader snaked through the 93-bed long-term care center, which is operated by the Sisters of Mercy with the support of the Catholic Church ... The outbreak on the Southwest Side was one of several nationally linked to the rare virus. But these incidents went largely unreported in the media, and in Chicago the Department of Public Health still is not releasing public records on the outbreak--an example of how health-care facilities and public agencies are able to keep damaging information about infections under wraps." 22 July 2002
Drug-resistant germs adapt, thrive beyond hospital walls
"Lapses in infection control and overuse of antibiotics are spawning drug-resistant germs that are spreading from hospitals into the community at unprecedented rates ... These new super germs--stronger, more elusive and deadlier--have multiplied for decades inside thousands of hospitals and now are hitching rides into outside communities on the clothes and skin of patients, workers and visitors." 23 July 2002
State falls short in tracking diseases
"The Illinois Department of Public Health's system for tracking infectious diseases is so flawed that it misses more cases than it catches, undermining the state's ability to react swiftly to emerging public health threats." 23 July 2002.
Nurse leads hospital's war on germs
"The success of Children's Hospital in Birmingham, Ala., underscores how any hospital can virtually eradicate infections, even among the sickest children." 22 July 2002.
Virus attacked Chicago children in outbreak kept under wraps
"The germ raced through the Misericordia Home for handicapped children in Chicago, masquerading as a cold-weather flu as it moved from bed to bed." 21 July 2002.
 Dana Carvey's botched bypass: fame confers no immunity to error
"After the operation, Carvey began to recover, and felt fine until he went out hiking near Lake Tahoe and felt the same burning sensation as before. When he got a check-up, doctors told him there seemed to be a problem with the way his blood was flowing. Carvey says that an angiogram, an X-ray of his blood vessels, revealed that the surgeon in San Francisco had bypassed the wrong artery. Carvey's stunned reaction was, 'Come again? Excuse me?'" The doctor who performed this surgery was California cardiologist Elias Hanna.
ABC News, 25 July 2002
Physician and Public Opinions on Quality of Health Care and the Problem of Medical Errors
"Most physicians believed that reduction of medical errors should be a national priority (69.7% of Colorado physicians). However, physicians were much less likely than the public to believe that quality of care is a problem (29.1% vs 67.6%; P<.001) or that a national agency is needed to address the problem of medical errors (24.1% vs 59.8%; P<.001). Uniformly, physicians believed that fear of medical malpractice is a barrier to reporting of errors and that greater legal safeguards are necessary for a mandatory reporting system to be successful. Nearly all physicians (92.9%) believed that more training in how to handle medical errors is needed, and 60.1% agreed that it is difficult to differentiate errors due to negligence from unintended errors."
Robinson et. al., Arch Intern Med. 2002;162:2186-2190
Prominent medical journals often provide insufficient information to assess the validity of studies with negative results
"Prominent medical journals often provide insufficient information to assess the validity of studies with negative results."
Hebert et. al., J Negat Results Biomed. 2002; 1 (1): 1
See also: Medical Error: 1988-2000
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Additional information
Medical Error: 1988-2000
Medical Error: Major Reports
Antibiotic overuse and microbial resistance
Psychiatrogenics
AiA Yahoo Group (hundreds of articles about medical error and practices.)
Harvard Risk Management Foundation
Medication errors
(FDA Center for Drug Evaluation and Research)
20 tips to help prevent medical errors
Agency for Healthcare Research and Quality
"Ladies and gentlemen, welcome aboard Sterling Airline's Flight Number 743, bound for Edinburgh. This is your captain speaking. Our flight time will be two hours, and I am pleased to report both that you have a 97% chance of reaching your destination without being significantly injured during the flight and that our chances of making a serious error during the flight, whether you are injured or not, is only 6.7%. Please fasten your seatbelts, and enjoy the flight. The weather in Edinburgh is sunny."
Would you stay aboard? We doubt it.
Luckily, the safety statistics in airline travel are far, far better than these figures. Between 1990 and 1994 United States airline fatalities were 0.27 per 1 000 000 aircraft departures, less than one third the rate in mid-century, despite vast increases in the complexity and volume of our aviation systems. One estimate is that a modern passenger would have to fly continuously for 20 000 years in order to reach a 50% chance of injury in an airplane accident.
In health care it is a totally different story. With the rising complexity and reach of modern medicine have come startling levels of risk and harm to patients. One recent study in two of the most highly regarded hospitals in the world discovered serious or potentially serious medication errors in the care of 6.7 out of every 100 patients,1 and the Harvard Medical Practice Study, which reviewed over 30 000 hospital records in New York state, found injuries from care itself ("adverse events") to occur in 3.7% of hospital admissions, over half of which were preventable and 13.6% of which led to death.2 If these figures can be extrapolated to American health care in general then over 120 000 Americans die each year as a result of preventable errors in their hospital care. The costs of medical errors are high in financial terms as well, estimated to be almost $4700 per preventable adverse drug event in one American teaching hospital.
> Reducing errors in medicine: it's time to take this more seriously
Donald M. Berwick and Lucian L. Leape
 When Ann Berwick was hospitalized in 1999 with symptoms of a rare autoimmune disorder of the spinal cord, she fell victim to many of the flaws in the U.S. health-care system ... Mrs. Berwick was scheduled for immediate treatment with a crucial drug. But even though she was gravely ill, she didn't get the first dose for 60 hours...Again and again, as new doctors got involved in the case, they repeated orders for other drugs that had already been tried unsuccessfully. Hospital staff gathered Mrs. Berwick's vital data, such as blood counts, body temperature and weight, in a disorganized way. And, on three occasions, they left her frightened and alone on a gurney late at night in a hospital subbasement..."Nothing I could do ... made any difference," recalls her husband, Donald Berwick, a Harvard-trained physician. "It nearly drove me mad."
> The Wall Street Journal, May 30, 2002.
"The number of people needlessly killed by hospital infections is unbelievable, but the public doesn’t know anything about it."
> Dr. Barry Farr, president of the Society for Healthcare Epidemiology of America.
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