The high rate of hospital medical errors has been acknowledged in all quarters of the health-care industry, and we’ve certainly done our share of blogging about it (“Why Can’t Hospitals Clean Up Their Medical Errors?“). Certain measures, such as the federal government’s error-reporting systems have been developed to address the problem.
But they’re not working, or at least not well enough, according to Dr. Philip Levitt, a retired neurosurgeon and former chief of staff of two hospitals. Writing in the Los Angeles Times, Levitt says, “American hospitals have a big problem with unnecessary deaths from medical errors. Estimates of the numbers vary widely, but extrapolating from the best studies, a conservative estimate would be that well over 100,000 people a year die unnecessarily because of errors made by their health-care teams. And the numbers have remained high despite concerted efforts to bring them down. Why? Because we’ve embraced a so-called solution that doesn’t address the problem.”
Levitt reminds readers that the hospital error wake-up call was sounded in 1999, when the Institute of Medicine (IOM) issued a report, “To Err Is Human.” It concluded that if hospitals implemented certain systems consistently, unnecessary deaths would drop by half within five years.
Since then, Levitt says, the medical profession has supported this “systems approach” that basically amounts to standardizing routine aspects of patient care. For example, no matter what hospital, no matter what patient, every heart attack victim is given an aspirin when entering the hospital; no matter what hospital, circumstance or patient, every surgical patient is given antibiotics just before the operation. Hospitals uniformly embrace checklists to ensure that all members of the treatment team follow accepted protocols.
Standardization, Levitt explains, wasn’t sufficiently tested in all medical applications. So the number of unnecessary deaths hasn’t dropped significantly. He refers to a recent study in the New England Journal of Medicine that compared rates of mortality and complications in some Canadian hospitals before and after they began using surgical safety checklists. Here’s what the researchers found: “Implementation of surgical safety checklists in Ontario, Canada, was not associated with significant reductions in operative mortality or complications.”
The reason, Levitt suggests, is simple: “Most preventable mishaps in hospitals are caused by the acts of individual practitioners, not flawed systems, and there was plenty of evidence of that fact available when the [IOM] wrote ‘To Err Is Human.'”
As so often is true in medicine, it comes down to people. The people who must apply art to science. The people who use the technology. The people who get paid, or not, for opting in or out of a certain procedure. Sometimes mistakes are not a human’s fault. But sometimes they are.
Levitt mentions several studies depicting human mistakes:
- A 1991 Harvard Medical Practice Study examined more than 30,000 randomly selected records from 51 hospitals; more than 6 in 10 incidents of harm to patients were because of either errors of technique or the failure of doctors to order the correct diagnostic tests. Only 6 in 100 adverse events were due to systems problems.
- A 2008 University of South Florida analysis of 10,000 surgical patients found that only 4 in 100 complications were attributable to flawed systems; the rest resulted from individual human shortcomings.
- A 2013 Baylor College of Medicine study found that most failures to diagnose arose from deficient physician performance during doctor-patient interactions, including poor history-taking, inadequate physical examinations or ordering the wrong tests. The study suggested that systems remedies, such as checklists and electronic medical records programs, would not address missed diagnoses because the problem is rooted in the doctors’ thinking.
- By 2006, more than 3,000 U.S. hospitals (more than 3 in 4 of the country’s acute care beds), had enrolled in a systems-based program called the 100,000 Lives Campaign, an outgrowth of recommendations in “To Err Is Human.” In 2010, researchers from Harvard and Stanford examined patient harms in hospitals in North Carolina, which had an enrollment rate of 96%. The researchers found no reduction in preventable patient injuries between 2002 and 2007.
“The major studies of what causes preventable errors,” Levitt writes, “have mostly failed to examine whether some doctors had a disproportionate number of bad outcomes. That failure has caused researchers to miss the most significant source of patient harm: incompetent doctors.”
But the data do define the problem. A former chief statistician for the National Practitioner Data Bank (a nonpublic federal repository of information about health-care providers in the United States) examined medical malpractice suits nationwide. He found that 2 in 100 U.S. doctors were responsible for half of the payouts over a 20-year period. An Australian study of 19,000 complaints against doctors over a 10-year period found that 3 in 100 of Australia’s doctors accounted for nearly half of all complaints.
“The institutions meant to protect patients from inept physicians are not doing an adequate job,” Levitt states.
- The average American hospital revokes the privileges of one doctor every 20 years.
- Only 250, or 0.04%, of the nation’s 650,000 physicians lose their licenses annually. “At that rate,” says Levitt, “it would take 50 years to remove the most dangerous 2% of doctors.”
- Only 1 in 100 patient harms is reported by hospitals to the 26 state health departments that require such reporting. Because 6 in 10 such harms are caused by the acts of individual doctors, an essential method for identifying erring doctors is blocked.
“These things all need to be addressed,” Levitt concludes, “if we are to prevent even some of the 1 million patient deaths likely to occur in the next decade.”