The Institute of Medicine dropped a bomb in 1999 when it reported that at least 44,000 and as many as 98,000 hospitalized patients die annually because of medical error. (1) Only the then-top four causes of death—heart disease, cancer, stroke, and COPD—claimed more than 98,000 people annually. You assumed more risk checking into a hospital than you did by traveling in an airplane or driving a car. (2)
The IOM’s report, titled “To Err is Human: Building a Safer Health System” and known simply as “To Err is Human,” was based upon two previously conducted studies, one analyzing 1992 data from Colorado and Utah (accounting for the 44,000 figure) and the other analyzing 1984 hospital records in New York (98,000). (3) You probably have seen these figures quoted in the media, with updates showing today’s hospital-error death toll to be 200,000, 300,000, or higher. “To Err is Human” gave rise to the modern field of patient safety.
The IOM, which is a nonprofit, nongovernmental organization, defined a medical error as a preventable injury caused by medical management. Notably, it did not fault individual actors, “bad apples” in the medical orchard, as many good-apple physicians wanted to do and had been doing. Instead, it condemned the U.S. healthcare system and culture, at large, especially within hospitals, but also in private physicians’ offices.
I wrote my book, “Our Parents in Crisis: Confronting Medical Errors, Ageist Doctors, and Other Healthcare Failings,” to illuminate the many systemic obstacles and failings, and other related problems, that I encountered during advocacy for my parents, who were savvy, informed patients rendered vulnerable by age and illness. I sought to alert other people to be on their guard.
Although I agree with the IOM that problems in communication and continuity of care (dropped “hand-offs” and lack of followup, for example) may sometimes be attributed to system flaws, I also met too many dismissive, indifferent, biased, and/or neglectful “apples” who created problems. Several of whom could be described as plain bad.
The following is an edited excerpt from “Our Parents in Crisis”:
INFECTIONS AND DRUG REACTIONS
In the aftermath of the IOM’s bomb, U.S. hospitals initiated reforms, targeting, in particular, the prevention of infections.
According to 2002 data published by the U.S. Centers for Disease Control and Prevention, about 2 million U.S. hospital patients, or one in every 20, contract nosocomial infections, and 80,000 to 100,000 of them die.
Nosocomial infections are hospital-acquired infections. They also may be described as iatrogenic, which means that the harm caused to a patient occurred because of medical treatment; physician action, inaction, or advice; and the like, such as negligent surgery or improper care. Nosocomial infections are an example of iatrogenesis.
Four types of nosocomial infection account for 80 percent of the CDC’s total:
• Urinary-tract infections, usually associated with a Foley catheter
• Infections of surgical sites or wounds
• Bloodstream infections, associated often with the use of an intravascular device that is a different type of catheter, and
• Pneumonia, typically because of respirator (ventilator) use (4)
The CDC reported that 80,000 U.S. patients annually develop infections because of intravascular catheters, and 30,000 of them die. These catheters are tubes placed in the neck, chest, or groin to administer medication and nutrients, drain fluids, or collect blood samples and may be used for weeks or longer.
Central venous catheter-related bloodstream infections, or so-called CRBSI, typically occur because of a failure by hospital personnel 1) to take adequate sanitary precautions when inserting the catheter or 2) to regularly assess a patient’s continued need for the device and to remove it as soon as possible. The longer an intravascular catheter remains in place, the greater the risk for a CRBSI. (5)
Some hospitals achieved great success in their post-IOM zero-tolerance infection campaigns, (6) but overall, the U.S. Dept. of Health and Human Services reported that, after 10 years, “very little progress” had been made. With the exception of cases of surgery-related pneumonia, which dropped 12 percent, the occurrence rates of most infections surveyed actually worsened. (7)
According to Dr. Lucian L. Leape, a chief author of the New York study underlying “To Err is Human” and a national figure in the patient safety movement, studies conducted since 1999 show that “half of Americans [overall, not just hospitalized] fail to get effective treatments they need, at least a third receive treatments of little or no benefit, and 10 percent or more are significantly harmed by preventable mishaps.” (8)
Common among the preventable mishaps are adverse drug reactions, which typically occur because physicians 1) ignore patients’ allergies, by neglecting to read the medical records that document their allergies; 2) fail to anticipate adverse effects that can be anticipated; or 3) fail to expect unexpected reactions. Doctors are not drug experts. (9)
Contemplating knee surgery in 2005, Dr. Donald M. Berwick, a former president of the Institute for Healthcare Improvement in Cambridge, Mass., put errors in perspective when he wondered: How can the healthcare system kill me? And then he counted some of the ways, writing:
“You can give me an infection during my surgery. You can mix up a blood transfusion. You can fail to prevent a pulmonary embolism. If I need a respirator for a while when I wake up, you can give me pneumonia. You can misplace a decimal point in the order for morphine. You can place the endotracheal tube by mistake in my esophagus (which, in the United States, happens on average in 8% of non-intensive care unit intubations) and not realize it until it is too late.”
Everything on his list, Berwick said, not only happens, but can be prevented, maybe not down to a rate of zero percent, “but awfully close to zero.” (10)
Nearly 15 years after “To Err Is Human,” John T. James, Ph.D., of Patient Safety America in Houston, reported that 440,000 deaths now occur in U.S. hospitals each year because of preventable causes.
James reviewed selected hospital studies published from 2008 to 2011 and developed an evidence-based estimate of patient harm associated with hospitalization. If he is correct, then preventable hospital error causes one-sixth of all deaths nationwide and is the third leading cause of death in the United States.
James also concluded that between 4 million and 8 million patients annually suffer nonlethal but serious harm as a result of hospital errors. (11)
There is good news, however, from the CDC, which reported in 2012 that the number of infections acquired in hospitals each year had dropped. In its most recent healthcare-associated infection (HAI) survey, the agency found that “on any given day” about one in 25 hospital patients has at least one healthcare-associated infection. This is down from one in 20, as reported by its 2002 survey. (12)
The conclusion for the patient is clear: Hospitals are a significant public-health hazard. You have to be aware of the risks and protect yourself, or find an advocate who will.
1. Institute of Medicine, Committee on Quality of Health Care in America, To Err is Human: Building a Safer Health System, ed. Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson (Washington, D.C.: National Academy Press, 1999), pp. 1, 26-28 [hereinafter cited as IOM, To Err is Human]. For information about the IOM, go to its website, http://www.iom.edu.
See also Julia A. Hallisy, The Empowered Patient: Hundreds of Life-Saving Facts, Action Steps and Strategies You Need to Know (San Francisco, CA: Bold Spirit Press 2008), p. 92; Gail Van Kanegan and Michael Boyette, How to Survive Your Hospital Stay: The Complete Guide to Getting the Care You Need—And Avoiding the Problems You Don’t (New York: Fireside, 2003), pp. xv-xvi; and Rahul Parikh, “It’s So Hard to Say I’m Sorry: The Financial and Personal Ramifications That Come When a Doctor Apologizes to a Patient,” at http://www.slate.com/id/2234322/pagenum/all/. (Dr. Parikh is a pediatrician in San Francisco.)
2. Eric J. Thomas, et al, “Incidence and Types of Adverse Events and Negligent Care in Utah and Colorado,” Medical Care 38 (2000): 261-71; Troyen A. Brennan, et al, “Incidence of Adverse Events and Negligence in Hospitalized Patients: Results of the Harvard Medical Practice Study I,” New England Journal of Medicine 324 (1991): 370-76; and Lucian L. Leape, et al, “Incidence of Adverse Events and Negligence in Hospitalized Patients: Results of the Harvard Medical Practice Study II,” New England Journal of Medicine 324 (1991): 377-84.
3. The top four causes were heart disease, malignant cancers, cerebrovascular disease (stroke), and chronic obstructive pulmonary diseases. See IOM, To Err is Human, p. 26; and U.S. Centers for Disease Control and Prevention (National Center for Health Statistics), National Vital Statistics Reports (1997 data), vol. 47, no. 19, June 30, 1999, p. 27.
4. R. Monina Klevens, et al., “Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002,” Public Health Reports 122 (2007): 160-66; and John P. Burke, “Infection Control—A Problem for Patient Safety,” New England Journal of Medicine 348 (2003): 651.
5. Leonard A. Mermel, “Prevention of Intravascular Catheter-Related Infections,” Annals of Internal Medicine 132 (2000): 394-97. Dr. Mermel lists recommended prevention strategies for intravascular catheter-related infections on p. 399.
In a major online survey, a majority of 2,075 responding infection-control workers cited the following factors as leading to CRBSI: insufficient time to train personnel on proper procedures; cumbersome paper-based systems for tracking patients; and neglect by ignorant and penny-foolish administrators. N.C. Aizenman, “Basic Practices Could Help Prevent Hospital Infections,” The Washington Post, July 13, 2010, p. A3; and “Preventable Bloodstream Infections Still a Problem in Hospitals, Infection Prevention Group Finds,” July 12, 2010 press release from the Association for Professionals in Infection Control and Epidemiology, obtainable at http://www.apic.org/AM/Template.cfm?Section=Home1.
6. In intervention studies conducted in intensive-care units, first at Johns Hopkins Hospital and then in 67 Michigan hospitals, prominent patient-safety advocate Peter Pronovost, M.D., Ph.D., of Johns Hopkins, showed that catheter-related bloodstream infections can be markedly reduced. Pronovost and his team achieved near-elimination of CRBSI in the Johns Hopkins ICU and a 66-percent reduction in 103 Michigan hospital ICUs statewide. Peter Pronovost, et al, “An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU,” New England Journal of Medicine 355 (2006): 2725-32; and Sean M. Berenholtz, Peter J. Pronovost, et al, “Eliminating Catheter-Related Bloodstream Infections in the Intensive Care Unit,” Critical Care Medicine 32 (2004): 2014-20.
7. The Associated Press, “Hospital Infection Rates Continue Alarming Rise,” April 15, 2010, at http://www.msnbc.msn.com/id/36465334/ns/health-health_care/ns/health-health_care/; see also Manoj Jain, “Focus on Patient Safety Hasn’t Succeeded,” The Washington Post, Dec. 21, 2010, p. E5.
HHS’s Agency for Healthcare Research and Quality (AHRQ) issues the National Healthcare Quality and Disparities Reports. According to HHS’s 2009 health-care quality report to Congress:
*Rates of bloodstream infections after surgery increased by 8 percent;
*Urinary infections from the use of a catheter after surgery (painful, but treatable with antibiotics) increased by 3.6 percent;
*The overall incidence of a number of common infections due to medical care increased by 1.6 percent; and
*The number of bloodstream infections due to central venous catheters remained essentially the same.
See AHRQ at http://www.ahrq.gov/qual/nhq09.
8. Lucian L. Leape, “New World of Patient Safety: 23rd Annual Samuel Jason Mixter Lecture,” Archives of Surgery 144 (2009): 394.
9. Jason Lazarous, Bruce H. Poneranz, and Paul N. Corey, “Incidence of Adverse Drug Reactions in Hospitalized Patients:A Meta-analysis of Prospective Studies,” JAMA 279 (April 15, 1998): 1200-05.
A patient reportedly can expect to be subjected to more than one medication error per day.: The Institute of Medicine, “Preventing Medication Errors,” Report Brief, July 2006, at http://www.iom.edu/Reports/2006/Preventing-Medication-Errors-Quality-Chasm-Series.aspx. Considerable variation in the number of errors exists from one medical facility to the next.
10. Donald M. Berwick, “My Right Knee,” Annals of Internal Medicine 142 (2005): 122.
11. John T. James, “A New, Evidence-Based Estimate of Patient Harms Associated with Hospital Care,” Journal of Patient Safety 9 (2013): 122-28. See also Tina Rosenberg, “To Make Hospitals Less Deadly, a Dose of Data,” The New York Times, Dec. 4, 2013, at http://opinionator.blogs.nytimes.com/2013/12/04/to-make-hospitals-less-deadly-a-dose-of-data/.
12. The HAI survey is based on data compiled from 183 acute-care hospitals in 10 states: California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New Mexico, New York, Oregon, and Tennessee. For a summary of the data, see U.S. Centers for Disease Control and Prevention, “Healthcare-Associated Infections (HAIs),” at http://www.cdc.gov/HAI/surveillance/index.html. For a full report, see Shelley S. Magill, Jonathan R. Edwards, et al, “Multistate Point-Prevalence Survey of Health Care-Associated Infections,” New England Journal of Medicine 370 (2014): 1198-1208. A table showing the infection types and their distribution appears ibid, 1204. A list of reported causative pathogens, according to infection type, is ibid, 1205.