Medical Errors Should Not Be Our 3rd Leading Cause of Death

Suppose two jumbo jets crashed every day, killing a total of about 365,000 people in a year. Remarkably enough that's about the level of carnage caused every year in our country by avoidable medical mistakes.
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Suppose two jumbo jets crashed every day, killing a total of about 365,000 people in a year. Remarkably enough that's about the level of carnage caused every year in our country by avoidable medical mistakes.

We would never tolerate such an incredible loss of life were it caused by recurring plane crashes (or most anything else). The Federal Aviation Authority would be given immediate and unlimited funding to figure out exactly why the planes were crashing and to do whatever it takes to make them safe again.

In fact, complete reporting of mistakes, and constantly correcting them, has made flying in a commercial plane about the safest thing a person can ever do.

In contrast, and inexplicably, we tolerate an equivalent loss of life caused by medical mistakes, despite the fact that they have become the third leading cause of death in the US. There is no public fear and rage, no sustained and coordinated effort to identify the major sources of error and eliminate them.

Neglect of medical safety has made the simple act of being admitted to a hospital about the most dangerous thing you can possibly do. And the hospitals and government are doing little to make medical care safer.
Things don't have to be this way. "Killer Care: How Medical Error Became America's Third Largest Cause of Death, and What Can Be Done About It" is a brilliant book by James Lieber that exposes the magnitude of medical mistakes, identifies their causes, and suggests solutions.

Mr Lieber writes: "Here are six obvious, practical, common sense, effective ways to prevent medical mistakes, reduce deaths, and lengthen lives.

1. Get Serious About Infections: About 100,000 die from healthcare-acquired infections annually, and more than a million people have their lives marred by these debilitating and unnecessary conditions. The Centers for Disease Control and Prevention (CDC) has evidence-based guidelines for disinfecting or sterilizing every forceps, scalpel, endoscope, autoclave, lab, patient room and air and water source in hospitals. Unfortunately, these standards are not regulatory and not strictly followed- unless there is an outbreak that forces local health departments to get in on the problem and police a cleanup. Obviously infection control practice should become mandatory, carefully regulated, and continuously monitored. US News & World Report and other raters should grade hospitals on their infection rates and the degree to which they adhere to CDC guidelines. Since infection nullifies the possibility of good treatment, ensuring compliance is just as important as who has the best doctors.

The best ways to prevent infections are also the simplest way- rigorous hand hygiene and identifying who are the carriers of infection. Doctors and nurses know they must wash all hand surfaces thoroughly for a full fifteen seconds. But behavior is spotty. A 2010 review of diverse hospitals pegged median compliance at 40%. The best fix is cameras- video recorders at sinks and alcohol dispensers which raises compliance to over 90% and keeps it there.

Some of the deadliest bugs in the world live in US hospitals- e.g., methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile, vancomycin resistant enterococci. Staff, patients and visitors bring infections into hospitals, often without knowing that they are infected. A simple nasal swab and culture costing about $20 can tell if someone carries MRSA. In 1995 MRSA accounted for 2 % of staph infections in America; today the rate exceeds 60%. Most other advanced countries have faced and defeated these dreaded bugs because, unlike the US, they mandated screening and methods of avoiding contamination. Denmark, Finland and Holland have reduced their ratio of MRSA to other strains of staph to below 1%. Every hospital should swab and culture. MRSA, by the way, has a death rate of almost 12%. More treatable, methicillin-sensitive Staphylococcus aureus (MSSA) kills about 5%. So simple screening can mean life or death for everyone in the care environment.

2. Clinical Pharmacy: A major breakthrough in twentieth century care allowed nurses to make rounds with doctors. Twenty-first century hospitals should also include pharmacists in rounds. The majority of medication mistakes involve physicians' initial orders. Doctors are not universal geniuses and shouldn't have to be. They know a lot about a lot of things, but compared to pharmacists, have a relatively thin knowledge of the ever multiplying world of drugs- how they interact with each other, diet, age, disease and body type. A comprehensive study of over 400,000 medication errors at 1116 hospitals showed that putting pharmacists in patient areas decreased errors by 45%. Errors leading to death, serious harm, or increased length of stay went down by 94%. Like infection controls, involving pharmacists in the practice team adds costs, but good hospitals have adopted it because it saves lives.

3. Structured Hand-Offs: Teamwork and careful communication are commonplace in the operating room, but often lacking on the other hospital units, especially when shifts change and tired residents brief their fresh successors. According to the Joint Commission, miscommunication during care transitions causes two thirds of "sentinel events" (deaths and serious injuries). A brilliant study of nine New England and Canadian hospitals reported in the New England Journal of Medicine in 2014 showed that structured hand-offs using concrete categories including illness severity, medical actions and contingency planning for patient crises reduced preventable adverse events by 30%. Structured hand-offs are also just as important in the emergency department where patients are passed among providers who gather information, take histories, try to tally all medications, order tests, assimilate results and admit patients or not. The average American emergency physician in a thirty-year career will send 44 patients home to die within 7 days.

4. Fight Diagnostic Error: The deadliest moment in medicine is diagnosis. A landmark longitudinal twenty-five year study of over 350,000 paid malpractice claims in the National Practitioners Data Bank (NPDB) showed that diagnostic errors caused the most deaths and serious injuries- and two thirds occurred in doctors' offices, rather than hospitals.

Diagnostic error takes multiple forms- including missed, wrong, delayed, partial and over diagnosis. Billing codes called Current Procedural Terminologies (CPTs) disallow payment for talking and emailing among clinicians, specialists and prior providers at the start of treatment. Clinicians cannot keep up with the exploding array of molecular, genetic and imaging technologies. Unable to bring pathologists and radiologists into the loop, they order no test or the wrong test, and come up with no diagnosis or a misdiagnosis. The National Academy of Medicine urges changes so clinicians can draw upon teamwork and real time review. Patients would be safer if doctors did not have to diagnose alone.

5. Make Electronic Medical Records (EMR) Interoperable: The Affordable Care Act included $36.5 billion for an EMR super highway to make all of a patient's history, lab results and medications available for current care decisions. Unfortunately, industry lobbyists prevailed on the Administration to disgorge the funds on closed source technologies rather than on interoperable systems- this has resulted in a balkanized patchwork of electronic providers. Different hospitals and doctors' offices' computers usually cannot communicate with each other, impeding diagnosis and jeopardizing treatment. A California trauma team may not know that its unconscious accident victim from Nevada has a drug allergy or respiratory condition requiring special antibiotic or anaesthesia controls. A 2014 study found that only 14% of clinicians shared data with doctors beyond their care organization. In 2015 Congress reacted with the Medicare Access and Children's Health Insurance Reauthorization Act directing interoperability within four years, but the legislation is longer on study than enforcement. Providers and patient advocates who abhor these absurdly dangerous barriers should advocate for and work towards a system whose parts can talk to one another.

6. Report All Medical Errors: There are two big debates about the reporting of medical errors. One is whether to make reporting mandatory or voluntary. The other is whether to report all medical errors or merely the most serious ones. In 2012, the Inspector General of the Department of Health and Human Services analyzed a total of 189 acute care facilities from all states and published "Hospital Reporting Systems Do Not Capture Most Patient Harm." Only a paltry 14% of adverse events were reported from these largely voluntary systems. One state, Pennsylvania, amazingly contributed 55 % of all the errors in the IG Study.

Why? In 2004, Pennsylvania became the only state to implement mandatory reporting of all medical errors including non-harm incidents sometimes called "near misses." In this way the Pennsylvania Patient Safety Authority echoed the FAA's widely admired Aviation Safety Reporting System. A recent five-year study concluded in 2013 showed that overall events went up somewhat during a period of rigorous detection, but that serious events leading to death or injury actually fell by 12%. Reports by Pennsylvanian doctors and nurses are non-discoverable in malpractice litigation. They can be anonymous, but out of over 2 million reports only a handful of providers chose not to use their names. Intensive scrutiny and full reporting make medicine safer and should become part of its culture everywhere."

Thanks so much, Mr Lieber. Your suggestions could save almost as many lives as curing cancer. And curing cancer may or may not happen, will surely take many decades, and will cost a fortune. Your cures for medical mistakes will surely work, can be done right now, and are incredibly cost effective.

Hippocrates, fathered modern medicine, but also warned of the grave risks of medical treatment. Twenty-five hundred years ago, he made "First, Do No Harm" the most essential dictum in all of medicine.

Unfortunately, doctors have not always honored his oath. Medical history is a recurring tale of doctors doing more harm than good with treatments that now seem ludicrously wrong headed and dangerous- bleeding, cathartics, emetics, and poisonous heavy metals.

George Washington didn't die from his sore throat; he was killed by his doctor's enthusiastic regimen of copious bleedings.

And things get more dangerous the more powerful and frequent our treatments and the less our doctors know their patients. Modern medicine has become so besotted by its remarkable technological firepower that it has neglected the simple safety basics. Hospitals compete to provide the fanciest settings rather than to provide the safest care. And doctors too often treat (often over-treat) lab tests, not people.

We are spending fortunes fighting failed "wars" against cancer and drugs- experience shows these are both mostly losing battles. We should instead begin to fight the winnable war to sharply reduce medically caused deaths. Implementing Mr Lieber's suggestions would likely save many more lives than will the most brilliant medical research advances of the next few decades.

Allen Frances is a professor emeritus at Duke University and was the chairman of the DSM-IV task force.

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