Preventable medical errors still taking their toll
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11/23/2010
John Fisher
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500 people die every day in American hospitals from preventable medical mistakes,

A 1999 report by the Institute of Medicine estimated that as many as 98,000 people a year died in hospitals from medical errors.  Now, 11 years later, a new report from the Department of Health and Human Services reveals that 1 in every 7 Medicare patients in hospitals suffers a "serious medical mishap".

The new report estimates that adverse events contribute to the deaths of an estimated 180,000 patients a year. This means that 500 PEOPLE DIE ON AVERAGE EVERY DAY FROM MEDICAL ERRORS IN THE NATION'S HOSPITALS. The "adverse events" include giving the wrong medication or administering an excessive dose of the right drug.  The extra medical care necessary to correct these mistakes costs taxpayers more than $4 billion a year.

Here's the really sad part of this new study: 11 years ago the Institute of Medicine issued specific recommendations to address the death toll caused by preventable medical mistakes, including the mandatory reporting of adverse medical outcomes to a central database. The goal of mandatory reporting of medical mistakes would have improved the ability of medical consumers to assess the quality of healthcare at hospitals and among physicians and that would have enhanced their ability to select the highest quality hospitals and careproviders. This never happened.

Now, 11 years later, the Department of Health and Human Services issued three specific recommendations to address preventable medical errors. The first remedy involves checklists: studies show that forcing surgeons and nurses to follow simple steps, such as washing their hands and wearing sterile gloves while inserting a central venous catheter, can dramatically lower infection rates and save lives.

The second remedy is transparency: Give consumers information about the quality of hospitals and physicians to allow them to become informed medical consumers.  The government runs the Hospital Compare website, www.hospitalcompare.hhs.gov) to allow patients to evaluate hospitals.

The third remedy involves financial incentives:Medicare will not pay for "never events".  A "never event", under Medicare regulations, is a medical mishap, such as operating on the wrong part of the body, administering the wrong medication, falls from a stretcher, pressure sores, surgical instruments and clamps left in the body after a surgery, etc.  The "never events" are hospital-acquired conditions that are considered "reasonably preventable".  The principle underlying the government's refusal to pay for "never events" is that hospitals should not profit from failure.

The three remedies proposed in the new study by the Department of Health and Human Services are well-conceived.  However, virually the same recommendations for mandatory reporting of medical mistakes was made by the Institute of Medicine in its 1999 report and look where it got us: NOWHERE!  The studies provide valuable information about the widespread death toll caused by medical mistakes, but in the past 11 years, very little has been done to fix this problem.

Medical societies, hospitals and physicians are opposed to a system that requires the reporting of their mistakes and I don't blame them.  I would not want to report my mistakes as a lawyer either!  However, the mandatory reporting of medical errors is the only way that the quality of care can be evaluated and consumers can make informed decisions in their selection of medical providers.

Mandatory report of medical errors should be required by law now. If not, we may be reading about another report concerning the death toll of medical mistakes years from now...in 2021.   

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John H. Fisher
130 North Front Street
Kingston, New York 12402-3058
Phone: 518.265.9131
Fax: 845-331-2004
Toll Free: 866.889.6882

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