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Medical Errors

Sources: "Medical Errors Blamed for Many Deaths: As Many as 98,000 a  Year in U.S. Linked to Mistakes," Washington Post, November 30, 1999, p. A1; Institute of Medicine (IOM), To Err Is Human: Building a Safer Health System (2000):

• "As many as 98,000 Americans die unnecessarily every year from medical mistakes made by physicians, pharmacists and other health care professionals according to [a] report released yesterday [by the Institute of Medicine, an arm of the National Academy of Sciences] that calls for a major overhaul of how the nation addresses medical errors." (Washington Post, A1)

• "Two large studies, one conducted in Colorado and Utah and the other  in New York, found that adverse events occurred in 2.9  and 3.7 percent of hospitalization, respectively. In Colorado and Utah hospitals, 6.6 of these adverse events led to death, as compared with 13.6 percent in New York. In both of these studies, over half of these deaths resulted from medical errors and could have been prevented." (IOM, Exec. Summary, p. 2).

Source: Brown, "Surgical Calamities on Rise, Group Says: Reports of Doctors Operating on Wrong Body Part--or Patient--Have Increased," Washington Post, December 6, 2001, A14, A15:

• "The number of surgical calamities in which a doctor operates on the wrong part of a patient's body, and occasionally on the wrong patient, appears to be increasing, according to the organization that accredits U.S. hospitals.  Reports of 'wrong-site' surgeries have risen from 16 in 1998 to 58 this year, including 11 in the last month, according to the president of the Joint Commission on Accreditation of Healthcare Organizations.  It is unknown whether this reflects a true increase in this most notorious type of surgical accident or simply more complete reporting of cases."  While these calamities occur in a very small number of cases out of 41.3 million surgeries performed in 1999, they are still cause for concern.  The reasons for concern are all the greater if the increasing trend represents real increases, not merely an increase in reporting. (A14)

• 'I think it's real,' said Dennis O'Leary, a physician who heads JCAHO . . . 'If you look at the trend line, you see an increase in every single year' since 1995.  .  . The preponderance of cases are in ambulatory surgery centers. . . . People are busy and patients are being put to sleep before there is an opportunity to verify who the patient is, what procedure is going to be performed and on what site."  (A14)

• "The mistakes include operations on the wrong finger, replacement of the wrong hip joint, fusion of the wrong spinal disk, cataract removal from the wrong eye, and biopsy of the wrong side of the brain.  A small number resulted in death.  Some had serious consequences, such as the removal of a healthy kidney instead of a cancerous one."  (A14)

• "The calamities occurred in outpatient or ambulatory surgical centers in 58 percent of [the reported] cases; in regular hospital operating rooms in 29 percent; and in emergency rooms or intensive care units in 13 percent. (About 70 percent of orthopedic cases now take place in outpatient surgical centers.)" (A15)

• "Analysts of medical errors have found that most calamites result from the accumulation of several oversights involving more than one person.  There is general agreement that altering systems is more important than changing the behavior of single individuals. . . . 'The need to systematically build in safety has not yet achieved a level of urgency in our health care systems, [according to O'Leary]." (A15)

Source: Robert Pear, "Medical Shift: Doctors' Errors To Be Disclosed," New York Times, January 2, 2001, p. A1, A12:

• "Reversing a policy that has kept medical errors a secret for more than two decades, federal officials say they will soon allow Medicare beneficiaries to obtain data about doctors who botched their care." (A1)

• "Tens of thousands of Medicare patients file complaints each year about the quality of care they receive from doctors and hospitals. But in many cases, patients get no useful information because doctors can block the release of assessments of their performance.  Under a new policy, officials said, doctors will not longer be able to veto disclosure of the findings of investigations." (A1) 

• Also in this regard, see Sealed Settlements and Lack of Right to Know Guarantee for Health and Safety Risks.)

Source:  Goldstein, "Overdose Kills Girl at Children's Hospital," Washington Post, April 20, 2001, B1, B4: 

• "A 9-month-0ld girl died last week after a misplaced decimal point caused a Children's Hospital nurse to administer a massive overdose of morphine [10 times the amount the doctor intended], illustrating a problem that plagues hospitals nationwide." (B1)

• "[The hospital's Chief Medical Officer] said the medication error consisted of three consecutive mistakes by a physician, a transcriber and a nurse." (B4)

• For a similar story involving allegations of an erroneously omitted decimal point resulting in a fatal overdose to a child, see "Nation in Brief - Lake Grove, N.Y." Washington Post, February 9, 2002, A28: "A missing decimal point on a prescription for a 6-day-old infant led to a deadly overdose, a lawyer for his parents said yesterday. . . . [The lawyer] announced plans to sue Stony Brook University Hospital over the death Tuesday of Gianni Vargas.  The baby's parents said officials told them the error was because of a prescription dosage reading 35, rather than 3.5.  The hospital's chief executive . . . issued a statement apologizing for an error, without specifying what it was."

Source:  "Two women died during heart surgery after they were mistakenly given an anesthetic instead of oxygen, hospital officials said today.  The women died after a meter that controls the flow of oxygen during operations was mistakenly plugged into an adjacent receptacle for nitrous oxide gas, a common anesthetic, Hospital of Saint Raphael [New Haven, CT], officials said.  Although the meter was equipped with safety prongs designed to prevent such a mistake, one prong was broken. . . . The second woman was not as sick as the first victim, officials said.  They said that when her oxygen levels began to dip during the procedure, the flow of gas was increased and she died on the table."  Associated Press, "Surgery Mixup Causes 2 Deaths," Washington Post, January 17, 2002, A5. 

Source: "A day after doctors performed a desperate second heart and lung transplant on a teenage girl, they announced she had permanent brain damage and little chance to live.  The girl, Jésica Santillán, a 17-year-old Mexican immigrant who came to North Carolina to get a new heart, is in a vegetative state, said a hospital official, Dr. Karen Frush, with 'severe and irreversible brain damage.'" Gettleman and Altman, "Doctors Say Girl in Donor Mixup Has Permanent Brain Damage," New York Times, February 22, 2003.  "In the first operation, Dr. James Jaggers implanted organs from a donor with type A blood, rather than Jesica's O-positive blood. . . . Hospital chief executive Dr. William Fulkerson said Jaggers wrongly assumed compatibility had been confirmed when he was offered the organs, and later failed to double-check that assumption, a violation of the hospital's procedures. Duke officials explained the error in a letter sent Friday to the United Network for Organ Sharing, which matches patients with donated organs." Dalesio, Associated Press, "Transplant Patient Has Brain Damage," February 22, 2003. 

Source:  Brown, "The End of an Error?: Big Business, Launching a New Era of Reform, Is Pressuring Hospitals to Cut Mistakes--and Costs," Washington Post, March 26, 2002, F1, F5:

• "Today, Xerox and more than 100 other large corporations (along with a few labor unions, nonprofits and government agencies) are embarked on a campaign to reduce medical errors, increase patient safety and enhance the care of hospitalized Americans.  They've drawn up a short list of specific goals they want the country's hospitals -- or at least the big ones -- to meet in the near future and, in effect, have nailed the list to the institutions' doors." (F1)

• These companies and their allies "hope to achieve the goals of safer, better and more efficient hospital care by sponsoring what amounts to a Patients' Crusade.  They want to get their employees to walk away from poor-performing institutions."  (F5)

• Solutions: "The main embodiment of this strategy is an organization launched two years ago called The Leapfrog Group, a collection of the country's biggest corporations that have agreed to promote and publicize three specific hospital practices: 

- "Computer software systems that replace paper-based ordering of drugs and medical tests.  'Computerized physician order entry' (CPOE) technologies eliminate errors that result from misread handwriting and can prevent overdoses, incorrect does, drug interactions, and allergic reactions arising from medications." Note: "The Institute of Medicine estimates that in-hospital medication errors cause 7,000 deaths a year.  CPOE systems can reduce these errors by 60 to 90 percent, according to several studies."

- "Limiting intensive care unit (ICU) staffing to physicians specially trained in intensive care medicine.  Research has shown that ICUs with so called 'closed staffing' have substantially lower mortality rates than ones in which primary care doctors manage the treatment of critically ill patients with experts providing consultation when asked." Note: "[O]ne researcher estimates that 50,000 could be saved [each year] with intensivist-only staffing."

- "The limitation of certain high-risk procedures to hospitals that do lots of them.  The relationship between high volumes and good outcomes in coronary bypass surgery and numerous other complicated therapies has been evident for years." (F5)  [See Villarosa article in April 11, 2002, New York Times and New England Journal of Medicine articles cited there for further substantiation of this recommendation.

- "[These three strategies] are backed by overwhelming and incontrovertible evidence of benefit." 

• "As the Leapfrog effort begins, statistics show plenty of room for improvement.  Only 5 percent of American hospitals have CPOE systems.  Only 10 percent of them meet the closed-staff ICU standard. . . . About half of coronary artery bypass operations and two-thirds of . . . operations that remove blockages in the arteries supplying blood to the brain are now done at what the group considers 'low-volume' hospitals." (F5)

Solution:  "Brigham and Women's Hospital in Boston said it has cut medication errors 86 percent from levels 10 years ago by using computers.  The computerized order entry system eliminates penmanship from the prescription process and automatically checks orders for appropriateness of drug selection and dosage based on the patient's clinical record."  Goldstein, "Overdose Kills Girl at Children's Hospital," Washington Post, April 20, 2001, B4.

Solution: "Hospitals must now tell patients and their families when they have been hurt by a medical error, according to nationwide standards that take place [July 1, 2001]. . . . 'These standards are meant to create a culture of safety,' says Dennis O'Leary, president of the Joint Commission on Accreditation of HealthCare Organizations (JCAHO), a non-profit group that accredits 80% of the nation's hospitals. . . . The new standards, available at www.jcaho.org . . . [demand] that hospital leaders tackle medical errors and patient safety -- or risk losing accreditation.  During regular inspections, the commission now will look for patient safety compliance from hospital CEOs down to the patients.  Each hospital in the USA must: Actively work to prevent errors; design patient safety systems, such as systems that double-check a drug order before a prescription is filled; and encourage and act on internal reports of errors."  Davis, "Accreditation at Risk if Patients Aren't Told," USA Today, June 28, 2001, A1. 

Solution:  Only 60 percent of U.S. orthopedic surgeons routinely physically mark or "sign" their operative site locations, although the American Academy of Orthopedic Surgeons in 1997 began a program called "Sign Your Site" to ensure that the right surgery is performed at the right site on the right patient.  Better implementation of this program could help reduce "wrong site" operations, according to Terry Canale, past president of the Academy.  Brown, "Surgical Calamities on Rise, Group Says," Washington Post, December 6, 2001, A15.

Solution:  Increasing medical staff levels and barring first-year residents from treating patients in [sensitive wards] such as the transplant ward.  See Saulny, "State Checks 41 Liver Surgery Cases at Hospital Where Donor Died," New York Times, April 5, 2002, which describes a transplant ward in which 34 patients were being cared for by "one first-year resident." The hospital has agreed to make these staffing changes.

Solution:   "Hospitals that do a high volume of certain operations report fewer complications — and in many cases fewer deaths — than those that do the operations less often, according to two studies published today.

"The studies and an accompanying editorial in The New England Journal of Medicine add to research and a touchy debate about whether certain types of care should be restricted to high-volume medical centers.

"One study, led by Dr. John D. Birkmeyer of the Veterans Affairs Medical Center in White River Junction, Vt., looked at 2.5 million Medicare claims from 1994 to 1999 and found that hospitals that performed a low number of six cardiovascular operations and eight cancer operations reported death rates 0.2 percent to 12 percent higher than high-volume hospitals in each procedure.

The other study, by Dr. Colin B. Begg of Memorial Sloan-Kettering Cancer Center in Manhattan, found that operations to remove the prostate had far fewer complications at high-volume hospitals."  Villarosa, "Studies Tie Success of Some Operations to Number a Hospital Does," New York Times, April 11, 2002.