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  Preventable Errors Still Causing Deaths Five Years Later

 


Researcher finds that medical errors are still high five years after Institute of Medicine's landmark report showing as many as 98,000 deaths are due to preventable errors each year.

Journal of the American Medical Association Article

"Five Years after To Err is Human: What Have We Learned?" Leape, Lucian L. & Berwick, Donald M., 2005
 
Five years after the Institute of Medicine (IOM) released its seminal report, To Err is Human, which concluded up to 98,000 Americans died each year from medical errors, the medical community has made little progress in reducing the risk to patients who use the healthcare system. An article by Lucian Leape, Adjunct Professor of Health Policy at the Harvard School of Public Health, in the Journal of the American Medical Association concedes that "the proven measured fruits of the IOM report so far are few."

Shift in the Focus of the Premium Crisis
One year after the IOM released its report, doctors began to report a surge in the cost of medical malpractice premiums. To many observers, this perceived crisis shifted the medical community's attention from saving patients to saving money. Leape believes that this crisis "has deflected interest of lawmakers from error prevention to an effort to put caps on malpractice settlements." The focus is now on how to minimize malpractice payouts rather than correct the errors that cause malpractice lawsuits in the first place.

Culture of Medicine is to Blame for Lack of Improvement
Leape outlines ways in which the structure of the healthcare system impedes the pathway to reduced medical error. They include:

  • Physicians reluctant to admit error—Physicians fear that admitting error is an admission of guilt and an easy avenue to a malpractice lawsuit. Thus, they are unwilling to embrace a new system that they feel would increase liability.
  • Lack of leadership at the hospital and health plan level—Efforts to implement safety measures have been met with stiff resistance from the boards of hospitals and health plans.
  • An insurance system that rewards error—The current reimbursement system actually rewards error by allowing physicians to bill for procedures necessitated by injuries they inflicted on patients through their mistakes.
  • The complexity of the healthcare system—With over 50 medical specialties and rising numbers of health-related professions, the risk that there will be a failure of communication within the system is increasing.
  • Perceived threat to authority and autonomy—Incorporating a system of safety measures requires physicians to relinquish independent judgment and authority for a system that requires interaction with others.
  • Lack of measures of improvement—There are few systems that comprehensively measure improvements, making it difficult to gauge how much progress has been made.

195,000 Preventable Deaths Every Year
In its report, the IOM estimated that 98,000 people die each year due to preventable medical errors, at a cost of $29 billion. Subsequent studies claim the number may be even higher. In 2004, HealthGrades released a report which found that the IOM severely underestimated the number of deaths caused by medical errors each year. Its data suggest that the true number was closer to 195,000 deaths annually, nearly twice the number reported by the IOM.

Funds for Safety Research Diverted
In 2001, in response to the IOM report, the federal government earmarked $50 million annually for patient safety research to be administered by the Agency for Healthcare Research and Quality (AHRQ). However, by 2004, most of this money had been shifted to fund studies of information technology. This suggests that the agencies in charge of developing and administering safety improvements do not understand the core of the problem.

Known Improvements are Not Implemented
The National Quality Forum (NQF), which has taken an active role in developing quality of care and standard of reporting measures, developed a set of practices to improve patient safety. By 2003, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) had mandated that hospitals implement only 11 of the 30 safety practices ready for use, or only slightly more than one-third of ready improvements.

Footnotes

  1. Leape, Lucian L. & Berwick, Donald M., "Five Years after To Err is Human: What Have We Learned?" Journal of the American Medical Association (JAMA), 2005.
  2. Leape & Berwick
  3. Leape & Berwick
  4. HealthGrades Quality Study: Patient Safety in American Hospitals, HealthGrades, July 2004.
  5. Leape & Berwick
  6. Leape & Berwick

Republished with permission of the Association of Trial Lawyers of America.  June 2005