Tag Archives: medical mistake

Medical Error Is Third Leading Cause of Death

A friend sent this to me… I made a few comments ***below.

Knowing a thing is different than being able to prove a thing. This is one of the reasons we advocate keeping a family member or friend with you 24/7 when you are in the hospital.

Cross ref this recent post in our blog.

We did not know of this study [below] when the above blog was written. ;]

Medical Error Is Third Leading Cause of Death in US
Marcia Frellick
May 03, 2016

Medical error is the third leading cause of death in the United States, after heart disease and cancer, according to findings published todayin BMJ.

As such, medical errors should be a top priority for research and resources, say authors Martin Makary, MD, MPH, professor of surgery, and research fellow Michael Daniel, from Johns Hopkins University School of Medicine in Baltimore, Maryland.

But accurate, transparent information about errors is not captured on death certificates, which are the documents the Centers for Disease Control and Prevention (CDC) uses for ranking causes of death and setting health priorities. Death certificates depend on International Classification of Diseases (ICD) codes for cause of death, so causes such as human and system errors are not recorded on them.

And it’s not just the US. According to the World Health Organization, 117 countries code their mortality statistics using the ICD system as the primary health status indicator.
The authors call for better reporting to help capture the scale of the problem and create strategies for reducing it.

Cancer and Heart Disease Get the Attention

“Top-ranked causes of death as reported by the CDC inform our country’s research funding and public health priorities,” Dr Makary said in an university press release. “Right now, cancer and heart disease get a ton of attention, but since medical errors don’t appear on the list, the problem doesn’t get the funding and attention it deserves.”

He adds: “Incidence rates for deaths directly attributable to medical care gone awry haven’t been recognized in any standardized method for collecting national statistics. The medical coding system was designed to maximize billing for physician services, not to collect national health statistics, as it is currently being used.”
The researchers examined four studies that analyzed medical death rate data from 2000 to 2008. Then, using hospital admission rates from 2013, they extrapolated that, based on 35,416,020 hospitalizations, 251,454 deaths stemmed from a medical error.

That number of deaths translates to 9.5% of all deaths each year in the US — and puts medical error above the previous third-leading cause, respiratory disease.

In 2013, 611,105 people died of heart disease, 584,881 died of cancer, and 149,205 died of chronic respiratory disease, according to the CDC.

The new estimates are considerably higher than those in the 1999 Institute of Medicine report “To Err Is Human.” However, the authors note that the data used for that report “is limited and outdated.”

Strategies for Change

The authors suggest several changes, including making errors more visible so their effects can be understood. Often, discussions about prevention occur in limited and confidential forums, such as a department’s morbidity and mortality conference.

Another is changing death certificates to include not just the cause of death, but an extra field asking whether a preventable complication stemming from the patient’s care contributed to the death.

The authors also suggest that hospitals carry out a rapid and efficient independent investigation into deaths to determine whether error played a role. A root cause analysis approach would help while offering the protection of anonymity, they say.
*** this is not going to happen. The hospital will view it as admitting fault ***

Standardized data collection and reporting are also needed to build an accurate national picture of the problem.
Jim Rickert, MD, an orthopedist in Bedford, Indiana, and president of the Society for Patient Centered Orthopedics, told Medscape Medical News he was not surprised the errors came in at number 3 and that even those calculations don’t tell the whole story.

“That doesn’t even include doctors’ offices and ambulatory care centers,” he notes. “That’s only inpatient hospitalization resulting in errors.”

“I think most people underestimate the risk of error when they seek medical care,” he said.
He agrees that adding a field to death certificates to indicate medical error is likely the way to get medical errors the attention they deserve.

“It’s public pressure that brings about change. Hospitals have no incentive to publicize errors; neither do doctors or any other provider,” he said.
*** and EVERY incentive to cover it up.***

However, such a major step as adding error information to death certificates is unlikely if not accompanied by tort reform, he said.
***exactly! ***

Still, this study helps emphasize the prevalence of errors, he said.
Human error is inevitable, the authors acknowledge, but “we can better measure the problem to design safer systems mitigating its frequency, visibility, and consequences.”
They add that most errors aren’t caused by bad doctors but by systemic failures and should ‘not be addressed with punishment or legal action.
*** one of those systemic issues often is a staffing or ‘man power’ thing. The need to see more volume of patients or clients to be able to make the money needed to pay for the staff required to do the PAPERWORK that the government and insurance companies require is way out of control.

The authors and Dr Rickert disclosed no relevant financial relationships.
BMJ. Published online May 3, 2016. 
Full text

Life imitates art

Life imitates art

One of the shows that I like to watch is “Criminal Minds”. In season 9 episode 24, “Demons” there is a scene where Spencer, one of the FBI agents, is in the hospital after being shot. The un-sub wants Spencer bumped off and sends a nurse in to administer a medication to Spencer that he is highly allergic to with the intention of killing Spencer. This was prevented largely because it was in the script… ;] OK, it was thwarted by both Spencer and Garcia having kept track of all the medications that had been given to Spencer along with the times and reasons.

While this is just a story, medication errors can and do happen AND can have fatal results.

Most of the time being in the hospital ends with good and expected results. However it is wisest to have a friend or family stay with your loved one 24/7 while they are in the hospital [and at medical appointments too]. As the patient and sitter, it is prudent to know what medication and treatments are ordered and why it is being ordered. Keep a record of all medications you [the patient] are given along with the time and who gave it. Yes the staff will be doing that too, the reason for keeping your own records is so that you can keep track in your own head and can ask questions if it seems appropriate. Another thing is that you should always get to know your care providers on a first name basis and about their background. This serves the purpose of general getting to know each other like most humans. It also makes you more human to your care providers. So instead of the gallbladder in room 5003, you are Sam Jones in room 5003 who had his gallbladder removed.

Most medication errors are the result of understaffing and over work. Another major contributing factor is when regular staff get ‘floated’ into another specialty area from their own. This floating is generally not something the staff likes to do because they know that they are less proficient in the area they go to. Part of the dislike of floating is that they could have already worked a few hours someplace else.

Sometimes the cause of medications errors is that the patient is complicated by many health issues. As an example let us say that the patient is pregnant with twins and develops a DVT [deep vein thrombosis] aka a blood clot, in this case of the leg. Being pregnant and high risk [twins and the DVT] she was placed on the OB floor. OB does not deal often with DVTs and Heparin. DVTs and heparin is mostly dealt with on medical floors or heart floors. So in a case like this the staff was not familiar with this medication and procedure.

A common treatment for this condition –DVT- is bed rest and blood thinners [Coumadin or in this case Heparin IV] even if the heparin is administered via an IV pump which is intended to very precisely give the ordered amount of medication over a specified time period. Sometimes the pump glitches and runs the medication in too fast which is not good. This happens often enough that as a safety tool we calculate how much fluid should be infused. The route is the bag of IV fluid with the ordered concentration of Heparin is hung on the IV pole, next is the Buretrol and then the pump into the patient. This calculated amount is placed in a Buretrol from the main bag, the feed from the main bag is clamped off to prevent more medication from going in. In this hypothetical case the clamp between the main bag and the Buretrol was not engaged which let the medication overload and could have harmed or killed the patient. By the way, the active agent in Rat Poison is – you got it, Coumadin.

While you are talking with the staff find out how many other patients your care provider has, what floor they normally work, how many hours they have already worked along with how many shifts they have worked in the last week. While you are at it ask them how often they have dealt with the medication and conditions in your case.

Survival concerns are common EVERY day we live.

Remember, we have to prepare to survive and thrive, every day.