The statement seemed a bit harsh at the time—most people would not consider a hospital stay as being dangerous in itself—but it was re-quoted as is. The very next day an article was published in the New York Times by Tina Rosenberg: To Make Hospitals Less Deadly, a Dose of Data. She presented results from a recent study that indicated that adverse events encountered by patients in hospitals were far higher than previous estimates had suggested.
These numbers are astonishing! This government source (2010) lists annual deaths from heart disease at 597,689 and cancer at 574,743. The next category, chronic lower respiratory diseases, comes in at 138,080. Accidental death is fifth on the list at 120,859. One begins to wonder why we worry so much about deaths from drunk driving when the carnage is so much greater in our hospitals than on our highways.
Another way to view these numbers is to compare this to deaths from airplane crashes. The rate is equivalent to 1205 deaths per day. That is equivalent to about four commercial aircraft crashes per day. Can you imagine what would happen if four aircraft crashed in a single day? The entire industry would be shut down indefinitely.
The report Rosenberg referred to can be found here. She chose to pursue the issue of lax data keeping that makes accumulating such numbers so difficult and so uncertain. Here we will be more interested in extracting information from that report, and learning more about the credibility of the reported estimates.
The report provides this background information:
The report uses the term "preventable adverse event" (PAE) to describe any harmful effect on a patient due to caregiver error. The observable effects from such mistreatment are not necessarily immediately recognizable. Some may take years to appear. The report lists some illustrative examples that also serve to indicate how difficult it is to arrive at an accurate estimate of the totality of PAEs.
The report was based on four preexisting studies of limited populations of patients. In each case a tool referred to as the Global Trigger Tool (GTT) was used to evaluate the medical records of the population of patients in order to discover suspicious events that might be PAEs. Physicians then reviewed these flagged records to decide if they should be considered as PAEs.
One study of Medicare patients is illustrative.
Based on this single study, preventable deaths of Medicare patients alone far exceed earlier estimates for the entire population. And remember that the number of preventable events that caused harm was 10 times greater. That means that Medicare patients suffered from poor care at the rate of 1.8 million times per year. Truly, hospitals are dangerous places for old people.
The four studies used to arrive at a total population estimate were based on different types of patients from different regions. The Medicare data, for example, could not be applied to the entire nation. Based on the results of the four studies, as reported, the report arrived at this preliminary conclusion:
However, there is plenty of evidence that medical records are not to be trusted. Doctors and hospitals not only get to bury their mistakes, they get to bury the evidence as well. These examples of sources of underreporting are provided.
"….some medical errors are not known by clinicians and only come to light during autopsies, which have found misdiagnoses in 20% to 40% of cases. ‘Aggressive’ searches for adverse drug events and prompted self-reports from clinicians have shown a much higher rate of adverse drug events than are evident in the medical records. A comparison of direct observation for medication errors with review of documentation in medical records in 36 hospitals and skilled-nursing facilities found that far more errors were found by direct observation than by inspection of medical records."
"A recent national survey showed that physicians often refuse to report a serious adverse event to anyone in authority. In the case of cardiologists, the highest nonreporting group of the specialties studied, nearly two-thirds of the respondents admitted that they had recently refused to report at least one serious medical error, of which they had first-hand knowledge, to anyone in authority. It is reasonable to suspect that clear evidence of such unreported medical errors often did not find their way into the medical records of the patients who were harmed."
The method of surveying medical records also neglects to count errors of omission.
It has been estimated that it takes about 10 years before an accepted medical finding makes its way into general usage by physicians. This delay can be lethal.
For all of these reasons, the estimate of PAEs based on the four studies had to be considered a lower limit. The final estimate essentially doubled the number of deaths and harmful events.
This might also be conservative and could be considered a lower limit.
How could things be so bad? Who is responsible?
The aircraft crash analogy that was used earlier was first made by Captain Sulllenberger, the pilot who became famous a few years ago when he successfully executed an emergency landing in the Hudson River. The American Hospital Association once invited Captain Sullenberger to give them a talk on how lessons learned in enhancing aircraft safety could be used to improve the quality of hospital care. He gave them an earful. First he provided this background on aviation practices.
"We worked to build a culture of safety that allows us to face an unanticipated dire emergency, suddenly, one for which we had never specifically trained, and saved every life on board…"
Then he pointed out that most medical errors are the result of system failures. Just as in the aviation industry, safety required the development of a culture where all participants were viewed as members of a team. A comparison is implied between the cowboy pilots of yesteryear and the doctors of today who choose not to bother with checklists, then he goes on to decry the current medical situation where it is assumed that when something goes wrong it is the result of an individual’s error.
In Sullenberger’s opinion, it is the hospital administrators who are at fault for not imposing systematic safeguards that could prevent most mistakes from occurring.
He continued on—optimistically.
Meanwhile, stay healthy! Your life may depend on it.