DEATH BY

MEDICAL ERROR

THE HIDDEN EPIDEMIC

By

William Charney

Editor of

“Epidemic of Medical Errors and Hospital-Acquired Infections”

What does the term “Medical Error” mean?

A combination of medical errors where doctors, nurses or health care workers make mistakes: Medical errors Health care acquired infections Misdiagnoses Medication errors Surgical errors that produce fatality or morbidity Blood clots Hospital-acquired uncontrollable diarrheas Outpatient errors Nursing home errors

Source: Dr. Gary Null and Joe Graedon, MS, and Teresea Graedon, PhD, “Top Screwups Doctors Make and How to Avoid Them”

Medical Error leading cause of death to Americans…

over 788,000 per year plus millions of injuries

Source: Extrapolation from Baker Report and the Public Health Agency of Canada 

Medical Error 2nd leading cause of death to Canadians…

approximately 56,517 to 63,098 deaths per year plus 552,473 adverse events

Systemic causes of medical error have been built into the design of the systems both in Canada and U.S.

Systemic Factors in Medical Error

Profit Motive:The Journal of General Internal Medicine

published a study in March 2000, titled “Hospital Ownership and Preventable Events”. It showed that patients in for-profit hospitals are 2 to 4 times more likely than patients at not-for-profit hospitals to suffer adverse events such as post surgical complications, delays in diagnosis, and treatment of an ailment.

Source: Vol. 15 No. 3 Pgs. 211-219

Factory Medicine in Canada

Number of: Patients per dayProcedures per dayOperations per hourPatients per minuteBeds per region

Systemic Factors in Medical Error (cont’d.)

Staffing:Patients in a hospital with a 1:8 nurse-to-

patient ratio, have a 31% greater risk of dying than patients in hospitals with a 1:4 ratio.

Only state with ratio regulation is California

No Canadian province has ratio regulation

Source: Aiken, et al; JAMA 288 No. 16 (2002) 1987-92

Systemic Factors in Medical Error (cont’d.)

Shift Work:Longer shifts translate into more errors.

Physicians who are scheduled to work long hours make 36% more errors with 5 times as many serious diagnostic errors

Source: Found in "Epidemic of Medical Error" CRC Press, ed. Charney, Chapter 9 authored by Pontus pp. 191

Systemic Factors in Medical Error (cont’d.)

Behavior: A study of 1,700 nurses, physicians, clinical

care staff and administrators found fewer than 10% address behavior by colleagues that routinely includes trouble following directions, poor clinical judgment or taking dangerous shortcuts. Specifically, 84% of MDs and 62% of RNs and other clinical care providers had seen coworkers taking shortcuts that could be dangerous to patients…fewer than 10% said they directly confront their colleagues.

Systemic Factors in Medical Error (cont’d.)

Non and Under Reporting:There are 27 states in the U.S. with

reporting regulations Quebec is the only province in Canada that

has reporting regulations5% and no more than 20% of medical error

incidents are reported

Source: Leape, JAMA 1994, Dec. 21 272(23) 1851-7

Systemic Factors in Medical Error (cont’d.)

Working Conditions:Poor working conditions, such as

ergonomics, patient developmental flows, staffing, workload, scheduling, and autonomy contribute directly to medical errors. In 115 studies included in a 2003 review, working conditions affect patient safety, the rate of medication errors, and the rate of recognition of such errors after they occur

Source: Blum et al; Natural Science Sleep 3 pp. 47-85

Systemic Factors in Medical Error (cont’d.)

Accountability:Studies have shown even getting

healthcare workers to wash hands between patients or after leaving bathrooms is not enforced and there are low compliance rates

52% of doctors did not wash their hands between patients

Source: CDC, 2003

Systemic Factors in Medical Error (cont’d.)

Cost-Benefit Analysis:The Society of Actuaries has stated that

medical errors are costing $20 billion a year. Bedsores alone account for a cost of $3.9 billion annually. The cost per patient of medical error can be as high as $20,000 per bed (using the American Hospital Association’s data of 1 million hospital beds in the U.S.)

Systemic Factors in Medical Error (cont’d.)

Injury to Workers: Injury contributes systemically to medical

error and compromises patient safety. Injuring a worker leads to a downstream

negative patient effect.

Source: Charney and Schirmer, AAOHN Journal - American Association of Occupational Health Nurses Journal)

Bullying:Nurses reported that 71% of bullying

behavior resulted in medical error of which 29% resulted in death

Systemic Factors in Medical Error (cont’d.)

Source: Rosenstein, et al. Joint Commission Quality Patient Safety 34(8) 467-71

Systemic Factors in Medical Error (cont’d.)

Technology: Reliance on technology is not a panacea for

solving medical errors. Human factors still apply.

Despite computerization of pharmaceutical approaches, 98,000 people per year end up in emergency rooms every year (mostly elderly) due to medication error.

Source: New York Times, 2012

Organizations in charge of fixing medical errors are organizations mostly responsible for creating problems

  

Patient advocacy groups and Canadian and American labor unions should lead the struggle to reform health care

Organizations in charge of fixing medical errors are organizations mostly responsible for creating problems

Patient advocacy groups and Canadian and American labor unions should lead the struggle to reform health care