According to a report from the Institute of Medicine, at least 1.5 million patients are harmed every year from being given the wrong drugs -- that's an average of one person per U.S. hospital per day. One reason these mistakes persist: Only 10% of hospitals are fully computerized, with a central database to track allergies and diagnoses, accodring Robert Wachter, chief of the medical service at UC San Francisco Medical Center. This well-known problem is not new news.
In 2000, a presidential task force labeled medical errors a "national problem of epidemic proportions." The task force estimated that the "cost associated with these errors in lost income, disability, and health care costs is as much as $29 billion annually."
Journal of the American Medical Association Volume 284 July 26, 2000
Dr. Barbara Starfield of the Johns Hopkins School of Hygiene and Public Health describes how the world’s most expensive health care system contributes to poor health and even death.
What does “iatrogenic” mean? “Induced in a patient by a physician's activity, manner, or therapy - especially a complication of treatment.”
Dr. Starfield offers several warnings in interpreting these numbers:
·First, most of the data are derived from studies in hospitalized patients.
·Second, these estimates are for deaths only and do not include negative effects associated with disability or discomfort.
·Third, the estimates of death due to error are lower than those in the older IOM report.1
If the higher estimates are used, the deaths due to iatrogenic causes would be 284,000. In any case, 225,000 deaths per year constitutes the third leading cause of death in the United States, after deaths from heart disease and cancer. Even if these figures are overestimated, there is a wide margin between these numbers of deaths and the next leading cause of death (cerebrovascular disease).
Another analysis 11 concluded that between 4% and 18% of consecutive patients experience negative effects in outpatient settings, with:
·116 million extra physician visits
·77 million extra prescriiptions
·17 million emergency department visits
·8 million hospitalizations
·3 million long-term admissions
·199,000 additional deaths
·$77 billion in extra costs
The high cost of the health care system is considered to be a deficit, but seems to be tolerated under the assumption that better health results from more expensive care.
However, evidence from a few studies indicates that as many as 20% to 30% of patients receive inappropriate care.
An estimated 44,000 to 98,000 among them die each year as a result of medical errors.2
This might be tolerated if it resulted in better health, but does it? Of 13 countries in a recent comparison,3,4 the United States ranks an average of 12th (second from the bottom) for 16 available health indicators. More specifically, the ranking of the US on several indicators was:
·13th (last) for low-birth-weight percentages
·13th for neonatal mortality and infant mortality overall 14
·11th for postneonatal mortality
·13th for years of potential life lost (excluding external causes)
·11th for life expectancy at 1 year for females, 12th for males
·10th for life expectancy at 15 years for females, 12th for males
·10th for life expectancy at 40 years for females, 9th for males
·7th for life expectancy at 65 years for females, 7th for males
·3rd for life expectancy at 80 years for females, 3rd for males
·10th for age-adjusted mortality
The poor performance of the US was recently confirmed by a World Health Organization study, which used different data and ranked the United States as 15th among 25 industrialized countries.
There is a perception that the American public "behaves badly" by smoking, drinking, and perpetrating violence." However the data does not support this assertion.
·The proportion of females who smoke ranges from 14% in Japan to 41% in Denmark; in the United States, it is 24% (fifth best). For males, the range is from 26% in Sweden to 61% in Japan; it is 28% in the United States (third best).
·The US ranks fifth best for alcoholic beverage consumption.
·The US has relatively low consumption of animal fats (fifth lowest in men aged 55-64 years in 20 industrialized countries) and the third lowest mean cholesterol concentrations among men aged 50 to 70 years among 13 industrialized countries.
These estimates of death due to error are lower than those in a recent Institutes of Medicine report, and if the higher estimates are used, the deaths due to iatrogenic causes would range from 230,000 to 284,000.
Even at the lower estimate of 225,000 deaths per year, doctor errors still constitute the third leading cause of death in the US, following heart disease and cancer.
Lack of technology is certainly not a contributing factor to the poor U.S. iatrogenic ranking.
·Among 29 countries, the United States is second only to Japan in the availability of expensive magnetic resonance imaging units and computed tomography scanners per million population.
·Japan ranks highest in health, whereas the U.S. (with spiraling medical costs) ranks among the lowest.
·It is possible that the high use of technology in Japan is limited to diagnostic technology not matched by high rates of treatment, whereas in the US, high use of diagnostic technology may be linked to more ineffective and inappropriate treatment.
·Supporting this possibility are data showing that the number of employees per bed (full-time equivalents) in the United States is the highest among the countries ranked, whereas they are very low in Japan, far lower than can be accounted for by the common Japanese practice of having their family members (rather than hospital staff) provide the basic amenities of hospital care.
About 2 million Americans a year now contract hospital-related infections. According to the Centers for Disease Control and Prevention about 90,000 a year are now dying annually from these hospital-caused infections (up for 80,000 in 2000, over 12% increase). These hospital infections have added about $4.5 billion a year to healthcare costs. The indiscriminate use of antibiotics have encouraged the rapid growth of new antibiotic-resistant bacteria that are becoming progressively more common in modern hospitals.
Not My Job: Good luck finding anyone responsible for the serious problems in your hospital. Helen Haskell told nurses something didn't seem right with her son Lewis, who was recovering from surgery to repair a defect in his chest wall. For nearly two days she kept asking for a veteran -- or "attending" -- doctor when the first-year resident's assessment was not helping. Haskell couldn't convince anyone that her son was deteriorating. "It was like an alternate reality," she says. "I had no idea where to go." Thirty hours after her son first complained of intense pain, the South Carolina teen died of a perforated ulcer. In a sea of blue scrubs, getting the attention of the right person is difficult. Who's in charge? Nurses don't report to doctors, but rather to a nurse supervisor. Your personal doctor has little say over radiology or the labs running your tests, which are managed by the hospital. Haskell urges patients to know the hospital hierarchy, read name tags, get the attending physician's phone number and, if all else fails, demand a nurse supervisor -- likely the highest-ranking person who is accessible quickly.
How do you tell a good hospital from a bad one? For one thing, nurses. When it comes to their own families, medical workers favor institutions that attract good nurses. But they're harder to find as the country's nursing shortage intensifies -- by 2020, 44 states will probably be facing a serious deficit. According to a 2001 study by Harvard and Vanderbilt University professors, low quantity / quality nurse staffing directly affects patient outcomes, resulting in more problems such as urinary tract infections, shock and gastrointestinal bleeding.
Another thing to consider: Your local hospital may have been great for welcoming your child into the world, but that doesn't mean it's the best place to undergo open-heart surgery. Find the facility with the longest track record, best survival rate and highest volume in the procedure; you don't want to be the team's third hip replacement, says Samantha Collier, vice president of medical affairs at HealthGrades, which rates hospitals. The new 2007 Massachusetts medical records automation is making this much easier. www.mass.gov/healthcareqc We encourage a similar nationwide online healthcare quality computerization.
The American Nurses Association's Web site lists "magnet" hospitals -- those most attractive to nurses. A call to a hospital's nurse supervisor should help you learn the nurse-to-patient ratio, says Gail Van Kanegan, an R.N. and author of How to Survive Your Hospital Stay. She also suggests calling the hospital's quality-control or risk-management office to get infection statistics and asking your doctor how frequently the hospital has done a certain procedure. While reporting these statistics is still voluntary, more hospitals are doing so on sites like www.hospitalcompare.hhs.gov, which compares hospitals against national averages in certain areas, including how well they follow recommended steps to treat common conditions, says Carmela Coyle, senior vice president for policy at the American Hospital Association.
Most hospital emergency room need urgent care. A new study from the Institute of Medicine found that hospital emergency departments are overburdened, underfunded, and unprepared to handle disasters as the number of people with no health insurance go to ERs for primary care keeps rising. An ambulance is turned away from an ER once every minute due to overcrowding, according to the study; the situation is exacerbated by shortages in many of the "on call" backup services for cardiologists, orthopedists and neurosurgeons. And it's getting worse. Currently, 73% of ER directors report inadequate coverage by on-call specialists, versus 67% in 2004, according to a survey conducted by the American College of Emergency Physicians.
If you can, avoid the ER between 3PM and 1AM -- the busiest shift. For the shortest wait, early morning -- anywhere from 4AM to 9AM -- is your best bet. If you are having severe symptoms, such as the worst headache of your life or chest pains, alert the triage nurse manager, not just the person checking you in, so that you get seen sooner, says David Sherer, an anesthesiologist and author of Dr. David Sherer's Hospital Survival Guide. Triage nurses are the traffic cops of the ER and your ticket to getting seen as quickly as possible.
Avoid hospitals in July. If you can, stay out of the hospital during the summer -- especially July. That's the month when medical students become interns, interns become residents, and residents become fellows and full-fledged doctors. In other words, a good portion of the staff at any given teaching hospital are new on the job.
Summer hospital horror stories aren't just medical lore: The adjusted mortality rate rises 4% in July and August for the average major teaching hospital, according to the National Bureau of Economic Research. That means eight to 14 more deaths occur at major teaching hospitals than would normally without the student turnover.
Another scheduling tip: Try to book surgeries first thing in the morning, and preferably early in the week, when doctors are at their best and before schedules get backed up, Sherer says.
According to a report by The Robert Wood Johnson Foundation, 95 percent of doctors state that they have witnessed a major medical mistake. These errors are NOT rare, they are both common and frequent.
All patients should listen carefully to their doctors about the options, risks, and recommendations. If you don't understand your doctor, find one who communicate effectively. Carefully read the information about new prescriiptions and pay close attention to your reaction to prescribed medications.
Patients who are told that they need surgery should also seek a second opinion. Most health plans will pay for it. If the opinions disagree, call your health plan and ask if they will pay for a third.
If you decide to accept the worst case risks of surgery, bring a family member or friend to a pre-surgical appointment to help you ask questions, gather hand outs, and write down all information and doctor statements.
It is important for patients to designate a “healthcare proxy” before surgery. The patient-appointed proxy can carry out the patient's wishes while the patient is under anesthesia or incapacitated. Before surgery, patients must sign a consent form, which they should read very carefully before signing. The form will describe exactly what the doctor is allowed to do, and whether a doctor will be allowed to proceed if more serious conditions are found. Another important document is a living will, which can protect a patient's rights and wishes in case the unexpected happens. Doctors need to know what they should do in terms of extraordinary life-saving measures.
All of this is minimal prudent behavior, but it cannot prevent the deadly or harmful major medical errors that do happen thousands of times every day of the year. The question that every patient must decide is whether the worst-case risks are worth the potential benefits of the medical procedure. All operations have some degree of life threatening risk, especially those requiring general anesthesia.