“Dead by Mistake” — the Staggering Death Toll of Medical Error

A new series of investigative articles by the Hearst newspapers concludes that errors in medical facilities are still taking some 100,000 lives per year — a decade after a national report first focused wide attention on the problem. Worse, the reforms that started after that report have been piecemeal and ineffective, according to the authors.

The series concudes:

[T]he federal government and most states have made little or no progress in improving patient safety through accountability mechanisms or other measures. According to the Hearst investigation, special interests worked to ensure that the key recommendations in the report — most notably a mandatory national reporting system for medical errors — were never implemented.

Among the key findings of the Hearst investigation:

• 20 states have no medical error reporting at all, five states have voluntary reporting systems and five are developing reporting systems;
• Of the 20 states that require medical error reporting, hospitals report only a tiny percentage of their mistakes, standards vary wildly and enforcement is often nonexistent;
• In terms of public disclosure, 45 states currently do not release hospital-specific information;
• Only 17 states have systematic adverse-event reporting systems that are transparent enough to be useful to consumers;
• The national patient-safety center is underfunded and has fallen far short of expectations;
• Congress approved legislation for “Patient Safety Organizations” as a voluntary system for hospitals to report and learn from errors, but the new organizations are devoid of meaningful oversight and further exclude the public;
• Hearst journalists interviewed 20 of the 21 living authors of “To Err is Human” — 16 believe that the U.S. hasn’t come close to reducing medical errors by half, the primary stated goal of the report;
• New York’s reporting system has run out of money and staff — its last public report is four years old;
• The law mandating reporting in Texas expired in 2007, and funding ran out — a new reporting law has been passed, but no funds have been allocated;
• Washington State requires reporting, but doesn’t enforce that requirement — and the legislature failed to provide funds to analyze the results.

If there is a silver lining in this cloud, it is that safety experts now know a lot more about how patients can keep themselves safe and secure in the health care system. I report their recommendations in my book, “The Life You Save: Nine Steps to Finding the Best Medical Care — and Avoiding the Worst.”

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