The Lancet, Volume 377, Issue 9774, Page 1289, 16 April 2011
The Lancet: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60520-5/fulltext?rss=yes
The US Institute of Medicine’s landmark 1999 report, To Err is Human: Building a Safer Health System, estimated that avoidable medical errors contributed annually to 44 000—98 000 deaths in US hospitals. Hospital-based errors were reported as the eighth leading cause of death nationwide, ahead of breast cancer, AIDS, and motor-vehicle accidents. The report put medical errors under the national spotlight.
Over 10 years later, the problem of medical errors remains and might even have escalated. In the April issue of Health Affairs, David Classen reports that as many as one in three patients in the USA encounters a medical error during a hospital stay. The most common are medication errors, followed by surgical errors, procedure errors, and nosocomial infections. The study also compared three different methods of detecting adverse events: voluntary reporting of sentinel events (as mandated by state and other oversight bodies), the commonly used Agency for Healthcare Research and Quality’s Patient Safety Indicators (which rely on automated review of discharge codes to detect adverse events), and the Global Trigger Tool pioneered by the Institute for Healthcare Improvement (which uses specific methods for reviewing medical charts that lead to further investigation into whether an adverse event occurred and how severe it was). The chart-review methodology picked up at least ten times more confirmed serious event cases (90% of 393) than did the other two methods (10% or 39 events). This finding suggests that the two currently used methods for detecting medical errors in the USA are unreliable, underestimate the real burden, and also risk misdirection of present efforts to improve patient safety.
Two other recent studies confirmed that medical errors in hospitals in the USA are a serious problem. Christopher Landrigan reported in 2010 that even in places where local governments have made efforts to improve safety of inpatient care, such as in hospitals in North Carolina, the high rate of detected events did not change over a 5-year period between 2002 and 2007. Similarly, a November, 2010, document from the Office of the Inspector General of the Department of Health and Human Services reported that, when in hospital, one in seven beneficiaries of Medicare (the government-sponsored health-care programme for those aged 65 years and older) have complications from medical errors, which contribute to about 180 000 deaths of patients per year.
Inevitably, medical errors increase medical costs. Also in the April issue of Health Affairs, Jill Van Den Bos of Milliman’s Denver Health practice reports that US medical errors cost US$17·1 billion in 2008 (0·72% of the $2·39 trillion spent on health care for that year). Ten types of error accounted for more than two-thirds of the total cost of medical errors—the top two being postoperative infections and pressure ulcers. The three most common medical errors were pressure ulcers, post-operative infections, and postlaminectomy syndrome.
Adverse medical events are also associated with a social cost defined by the harm induced. John Goodman of the National Center for Policy Analysis in Dallas, TX, reports in the same publication that the value of lost lives and disabilities caused by injury in the USA in 2006 ranged from $393 to $958 billion—equivalent to 18—45% of total US health-care spending in that year. At present, US patients are usually not offered voluntary and no-fault insurance that would compensate if an adverse event occurs. Needless to say, the USA currently has few policies that compensate patients harmed by medical errors, of whom fewer than 2% file a malpractice suit and a much smaller proportion receive any form of compensation.
Who or what is to blame for medical errors and their consequences? Overworked providers, an unnecessarily complex medical system, or uninformed patients? Patients are often handed from one doctor to another and, in the process, communication between providers can break down. Time spent filling out paperwork is time not spent with patients improving the quality of their care. Decision making often does not involve informing a patient about the balance between benefits and harms of individual treatments, or incorporating patients’ goals into planned treatment. And it does not help that existing guidelines allow medical residents in the USA to work on average 28 h more per week than junior doctors in countries of the European Union.
US health providers and policy makers must make patients’ safety a national priority. A good start in the right direction will be to implement at the federal level a mandatory and comprehensive nationwide monitoring system to track medical errors.