PEOPLE FREQUENTLY INJURED BY MEDICAL ERRORS

By Arthur A. Levin, MPH

It has been two and one-half years since the Institute of Medicine (IOM) issued its groundbreaking report on medical errors. Having been part of the IOM effort, I had high hopes that it would finally force the health care system to confront the crisis in patient safety with a sense of urgency. But as the months go by, I become less and less convinced that a sufficient number of doctors and hospitals are committed to doing whatever is necessary to stem the tide of death due to medical mistakes. Instead, some have chosen to focus on debunking the IOM's calculations as unscientific and grossly exaggerated, thus denying the problem exists rather than fixing it.

The IOM concluded that between 44,000 and 98,000 hospitalized patients suffer a fatal injury because of medical errors each year. It has responded to its critics by pointing out that this is likely an underestimate of the true dimensions of patient injury for several reasons. First, the IOM's estimate is based on errors only in hospital care. In other words, the type of care that is rapidly shifting into ambulatory settings; and second, medical mistakes are well known to go unrecognized and undocumented in hospital medical records.

Until now, there has been little evidence of the risks patients face from medical errors occurring outside of hospitals. But, two recent studies appear to support IOM's view that the 44,000 to 98,000 range is likely an underestimate. Alan J. Forster, MD, and colleagues from the University of Ottawa and Harvard Medical School interviewed 400 patients discharged from a large unnamed teaching hospital and reviewed their medical records. One out of five were found to have suffered an "adverse event" after leaving the hospital (Annals of Internal Medicine, 2/4/03). An adverse event was defined as a treatment-related injury rather than one due to the underlying medical condition. Two thirds of all reported injuries in this study were due to drug errors and a majority was judged preventable.

The researchers point out that their study is probably biased towards underestimating risk because "The sicker patients …too ill to speak on the phone for 20 minutes, readmitted to the hospital, or [who] had died either declined or were incapable of responding."

In a second study, Jerry Gurwitz MD, University of Massachusetts Medical School, and colleagues, reviewed the experiences of 27,000 seniors enrolled in a Medicare HMO. (JAMA 3/3/03) Over the course of a year, the researchers identified 1,523 adverse drug events, a third of which were judged "serious, life threatening or fatal" and two out of five were the result of preventable errors. In an accompanying editorial, David Classen, MD, points out that extrapolation from of the study's findings would suggest that as many as 180,000 life-threatening or fatal adverse drug events may occur in the Medicare population each year.

Even consumers may be ignoring the risks they face in their encounters with doctors and hospitals. Robert J. Blendon, ScD, Harvard School of Public Health and colleagues, conducted a study of 1,207 people, including 831 doctors, to find out their attitudes about medical errors. (New England Journal of Medicine, 12/12/02) Four out of ten consumers surveyed reported an error in their own care or that of a family member-almost half of which were serious or fatal. Yet, when asked to choose whether 500, 5,000, 50,000, 100,000 or 500,000 deaths came closest to the actual number of patients fatally injured each year in U.S. hospitals, a majority chose 5,000, far below the IOM estimate and incongruous with their own experience. Coincidentally, 5,000 was also the figure picked by the majority of doctors surveyed.
That consumers underestimate the potentially deadly consequences of error may explain why, despite the mounting evidence of harm, there is so little public outcry over the lack of substantial progress in making health care safer. The current slow pace of change is costly-tens of thousand of lives have been lost since the IOM first issued its report. Many of these lives could have been saved by faster and more decisive action. In the meantime, kept in the dark about the safety records of doctors and hospitals, consumers are left to navigate on their own and to hope they have made the right choice.

 

(April 2003)