Deaths by medical mistakes hit records

The way IT is designed remains part of the problem
By Erin McCann
05:58 AM
It's a chilling reality – one often overlooked in annual mortality statistics: Preventable medical errors persist as the No. 3 killer in the U.S. – third only to heart disease and cancer – claiming the lives of some 400,000 people each year. At a Senate hearing Thursday, patient safety officials put their best ideas forward on how to solve the crisis, with IT often at the center of discussions. 
Hearing members, who spoke before the Subcommittee on Primary Health and Aging, not only underscored the devastating loss of human life – more than 1,000 people each day – but also called attention to the fact that these medical errors cost the nation a colossal $1 trillion each year.  
"The tragedy that we're talking about here (is) deaths taking place that should not be taking place," said subcommittee Chair Sen. Bernie Sanders, I-Vt., in his opening remarks.
Among those speaking was Ashish Jha, MD, professor of health policy and management at Harvard School of Public Health, who referenced the Institute of Medicine's 1999 report To Err is Human, which estimated some 100,000 Americans die each year from preventable adverse events
“When they first came out with that number, it was so staggeringly large, that most people were wondering, 'could that possibly be right?'" said Jha. 
Some 15 years later, the evidence is glaring. "The IOM probably got it wrong," he said. "It was clearly an underestimate of the toll of human suffering that goes on from preventable medical errors."
It's not just the 1,000 deaths per day that should be huge cause for alarm, noted Joanne Disch, RN, clinical professor at the University of Minnesota School of Nursing, who also spoke before Congress. There's also the 10,000 serious complications cases resulting from medical errors that occur each day. 
Disch cited the case of a Minnesota patient who underwent a bilateral mastectomy for cancer, only to find out post surgery a mix-up with the biopsy reports had occurred, and she had not actually had cancer. 
                "Medicine today invests heavily in information technology, yet the promised
              improvement in patient safety and productivity frankly have not been realized."
                                                                                                          - Peter Pronovost, MD
In terms of how to address this crisis, the recommendations put forth were diverse – including boosting the number of registered nurses, supporting AHRQ, CDC and establishing incentives. There did, however, exist common agreement with one thing: information technology is falling short in many arenas. 
"Medicine today invests heavily in information technology, yet the promised improvement in patient safety and productivity frankly have not been realized," said Peter Pronovost, MD, senior vice president for Patient Safety and Quality and director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins.
Jha agreed. There's been so much hype around electronic health records, with the industry showing "phenomenal progress" with adoption and use. "But the potential is not going to be realized unless those tools are really focused on improving patient safety," he said. "The tools themselves won't automatically do it."
Tejal Gandhi, MD, president of the National Patient Safety Foundation, added: The IT needs to be improved. "We need better systems to minimize cognitive errors…such as computerized algorithms," she said, speaking on behalf of ambulatory patient safety.
One of the more significant issues relating to ambulatory medical errors involves missed and delayed diagnoses, she pointed out, for instance failing to order appropriate tests or initiate follow up. The IT systems, she continued, need to be designed to better manage test results. 
And other key recommendations?
Jha pointed out: Data and metrics are key. 
"If you don't have data and metrics, you don't know how you're doing; you don't know how you compare to anyone else, and you have no way to judge whether your efforts are making a difference or not," he said. 
Jha advocated on behalf of giving the Centers for Disease Control and Prevention the job of collecting and monitoring this data. 
Pronovost agreed, as currently, there exists no "guarantee that the measures that we're reporting are accurate," he said.
               "What these numbers say is that every day, a 747, two of them are crashing." 

For instance, he referenced the time when Johns Hopkins was both congratulated and criticized for its performance on blood stream infections, pertaining to the same measures and the same time period. "The one we're paid on using administrative data, got it right 13 percent of the time," he said. 

"Why is it when a death happens one at time, silently, it warrants less attention than when deaths happen in groups of five or 10?" he asked. "What these numbers say is that every day, a 747, two of them are crashing. Every two months, 9-11 is occurring…we would not tolerate that degree of preventable harm in any other forum."
In the hearing's closing questions, when Sanders inquired as to why this crisis was not constantly splashed across front page news, he was met with this: "When people go to the hospital, they are sick. It is very easy to confuse the fact that somebody might have died because of a fatal consequence of their disease, versus they died from a complication from a medical error," Jha said. "It has taken a lot to prove to all of us that many of these deaths are not a natural consequence of the underlying disease. They are purely failures of the system."
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