OP-ED

Why We Still Kill Patients

A recent front-page article [1] in the New York Times conveyed grim news about patient safety. The first large-scale study [2] of hospital safety in a decade concluded that care has not gotten significantly safer since the Institute of Medicine’s 1999 estimate [3] of up to 98,000 preventable deaths and 1 million preventable injuries annually.

What for me struck a particularly jarring note was not just the absence of improvement, but the reluctance of the health care leaders interviewed to speak candidly about why progress has been so slow. Instead, they offered nostrums about the need to “do more” or opined that “openness” or better “coordination” would somehow turn the tide.

But tucked in the actual study’s conclusions section, between bland boilerplate about “further study” and a “refocusing of resources,” some carefully worded candor cautiously peeked through: “[T]he absence of large-scale improvement is not evidence that current efforts to improve safety are futile,” wrote Christopher Landrigan and colleagues in the Nov. 25 New England Journal of Medicine. “On the contrary, data have shown that focused efforts to reduce discrete harms, such as nosocomial infections and surgical complications, can significantly improve safety.”

In plain language, we know how to prevent many of these patient deaths, but we don’t. That makes, “Why?” a lot tougher question.

It is a question that has haunted me since I discovered that clear descriptions of the medical error problem, its human cost and the corrective actions needed began appearing in the medical literature in the 1950s. The first large-scale study of hospital safety, by Don Harper Mills in California [4], was published in 1978. My extrapolation of its findings [5] showed a preventable national death rate of about 120,000 patients annually. That’s roughly the same as the numbers from the oft-quoted Harvard Medical Practice Study [6] published in 1991 that the IOM relied upon in its 1999 To Err is Human report. In human terms it means that 2.5 million men, women, and children died preventable deaths in U.S. hospitals during the 21 years between 1978 and 1999. A staggering seven to 17 million suffered preventable injuries.

The Silence Continues

I laid out those numbers in a March, 2003 Health Affairs article [7] that challenged the profession to break a silence of deed — failing to take corrective actions — and a silence of word — failing to discuss openly the consequences of that failure. This pervasive silence, I wrote:

continually distorts the public policy debate [and] gives individuals and institutions that must undergo difficult changes a license to postpone them. Most seriously of all, it allows tens of thousands of preventable patient deaths and injuries to continue to accumulate while the industry only gradually starts to fix a problem that is both long-standing and urgent.

Nearly eight years later, medical professionals now talk freely about the existence of error and loudly about the need for combating it, but silence about the extent of professional inaction and its causes remains the norm. You can see it in this latest study, which decries the continuing “patient-safety epidemic” while failing to do next what any public health professional would instinctually do: tally up the toll. Instead, we get dry language about the IOM’s goal of a 50 percent error reduction over five years not being met.

Let’s fill in the blanks: If this unchecked “epidemic” were influenza and not iatrogenesis, then from 1999 to date it would have killed the equivalent of every man, woman and child in the cities of Raleigh (this study took place in North Carolina) and Washington, D.C. Does a disaster of that magnitude really suggest that “further study” and a “refocusing of resources” are what’s needed?

Why are we still killing so many patients? Call it the “three I’s”: invisibility, inertia and income.

The invisibility issue is commonly articulated this way: while airplane crashes kill a lot of people at once in a very public manner, medical error kills a few people at a time in private, spread out among thousands of hospitals. Moreover, most deaths occur among those who were already very sick, and only a small proportion represent negligence. This is inadvertent harm; there are no villains here. In any event, medical care is complicated. As a result, as a 2009 JAMA commentary [8] pointedly noted, “Clinicians have labeled virtually all harm as inevitable for decades.”

That conviction is conveyed to and largely believed by patients. Why else would the advocacy groups for the sickest patients, such as the American Cancer Society or American Diabetes Association, pay so little attention to treatment-caused harm?  Absent public or peer pressure, doctors and hospitals are reluctant to adopt interventions whose efficacy they mistrust to prevent an epidemic they really don’t see and which is profoundly discomfiting [9]to confront.

Letting Children Die Unnecessarily

There are many examples of the inertia these beliefs produce, but one I cannot get out of my mind concerns sick children. At the 2009 AcademyHealth meeting, Dr. Richard Brilli of Nationwide Children’s Hospital presented data showing how a collaborative backed by some of the most respected organizations in pediatric care had slashed the rate of catheter-associated bloodstream infections (CA-BSIs). CA-BSIs are relatively common, very expensive and can be quite deadly (up to one quarter of victims die). Brilli said his collaborative had tried to recruit 330 pediatric intensive care units to join the initial participants, but after three years, just sixty had accepted. The reasons Brilli said he’s been given indicated to me that few had taken the time to examine the collaborative’s methodology or results. Instead, respondents asserted that their patients were sicker, their hospital was busier than the others in the study, that joining would make them look bad to others, or that the mortality reduction didn’t apply because “I am in a world famous center.”

Now fast-forward to the February, 2010 issue [10] of Pediatrics, in which the collaborative concluded: “CA-BSIs are a preventable cause of patient harm to critically ill children.” What you can’t see in the peer-reviewed literature is this context: at literally scores of hospitals which declined to participate in the collaborative, hundreds of sick children likely were injured or killed who probably would not have been harmed had the hospital been a collaborative member. Those harmed were tended to by dedicated staff who thought they were doing everything they could to help the kids in their care. They were dead wrong, but even today they may not know it. Certainly, their patients and the public do not.

I’ll cite just two other examples of inertia and invisibility interacting to impede change. When the Institute for Healthcare Improvement launched its “Save 100,000 Lives” Campaign [11] on the fifth anniversary of the IOM report (the delay speaks for itself), four out of 10 U.S. hospitals still declined to participate. No policymakers or commentators questioned why 40 percent of hospitals would sit out this opportunity to improve care.

Another example: the Centers for Disease Control and Prevention published its first hand-washing guidelines in 1975. Yet nearly 35 years later, when the Joint Commission launched an improving hand hygiene project, the eight hospitals that volunteered had a baseline hand hygiene rate typical of hospitals nationwide: 48 percent.  That’s worse than the worst rate at the worst big public men’s room in the United States [12], according to one recent survey. But rather than giving providers an ultimatum, we launch campaigns to ask patients to ask providers to please wash up.

Most lethal of all is when invisibility and inertia interact with income. Ironically, the modern patient safety movement owes its foundational data to providers’ belief that malpractice insurance premiums were too high. The landmark studies of medical error published in 1978 and 1991 were backed by physician groups which hypothesized that unjustified lawsuits, not actual medical problems, were driving up premiums. In the event, research demonstrated that only a small percentage of errors resulted in lawsuits and an even smaller percentage in judgments. By that yardstick, the most recent study represents progress, since it was motivated by care improvement rather than income protection. Still, provider fear of being unjustly sued no doubt obstructs needed sharing of information and argues for malpractice reform.

Confronting The Belief That Complications Bring Extra Income

But there’s another elephant in the room that makes providers squirm even more. Put bluntly, many hospital executives believe they make money from complications. (Not from deaths, of course, because those shorten length of stay). Frustrated clinicians have personally told me this many times over the years, and as recently as a few weeks ago. The evidence has even made its way into the medical literature.

To cite just one example, let’s go back to those expensive bloodstream infections that affect the most vulnerable of patients, critically ill children, being cared for at the most eleemosynary of institutions, children’s hospitals. Even here, clinicians find themselves forced to argue that there is a “business case” for reducing CA-BSI’s in the pediatric intensive care unit.

In a recent journal article [10], the authors framed their case this way: Yes, infections increased the hospital stay by an average of nine days, and yes, insurers saved more money than hospitals by eliminating them. However, if a hospital filled the beds vacated by non-injured patients, it actually made more money because new patients provided more revenue in the first few days than tacking on those days to the hospital stay of patients already in the ICU. A clinical and financial win-win!

The Unknown Success Story Of Ascension Health

The ultimate irony about the silence surrounding patient safety is that one of the most extraordinary success stories in preventing harm has largely gone unheard. Ascension Health looks like most of the U.S. health care system, operating 65 community hospitals with independent medical staffs. Yet its program to eliminate all preventable injuries or deaths has been highly effective. They have carefully documented how they reduced infections, falls, complications of childbirth and a host of other common causes of patient harm to a fraction of national norms and saved more than 2,000 lives every year.

The clinical and  administrative leaders of Ascension Health, one of the nation’s largest Catholic health systems [13], made the invisible visible, and found that errors were far more prevalent than they thought. They declared that inertia would not be tolerated; all their affiliated hospitals had to participate. And they were willing to risk hospital income to prove that they were serious about change.

It is a story that so far seems to have excited only a few conference goers and regular readers of the Joint Commission Journal, which has been publishing articles [14] about Ascension’s results since 2006.

As a society, we know what combination of social pressure, economic incentives and provision of tools to enable new behavior lead to transformational change. In patient safety we are using all of them, including various public and private programs to refuse payment for preventable error and publicize hospitals’ safety records [15]. But at the front lines of patient care, it is all too clear that these efforts have yet to make much of a difference, as well-intentioned professionals silently turn away from the preventable harm we are still inflicting on those we are working so hard to help.


Article printed from Health Affairs Blog: http://healthaffairs.org/blog

URL to article: http://healthaffairs.org/blog/2010/12/06/why-we-still-kill-patients-invisibility-inertia-and-income/

URLs in this post:

[1] article: http://www.nytimes.com/2010/11/25/health/research/25patient.html?_r=1&scp=1&sq=safety%20hospital&st=cse

[2] study: http://www.nejm.org/doi/full/10.1056/NEJMsa1004404

[3] Institute of Medicine’s 1999 estimate: http://www.iom.edu/Reports/1999/To-Err-is-Human-Building-A-Safer-Health-System.aspx

[4] Don Harper Mills in California: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1238130/

[5] My extrapolation of its findings: http://www.press.uchicago.edu/presssite/metadata.epl?mode=synopsis&bookkey=3615128

[6] Harvard Medical Practice Study: http://www.ncbi.nlm.nih.gov/pubmed/1987460

[7] March, 2003 Health Affairs article: http://content.healthaffairs.org/cgi/content/abstract/22/2/103

[8] 2009 JAMA commentary: http://jama.ama-assn.org/cgi/content/short/301/12/1273

[9] profoundly discomfiting: http://onlinelibrary.wiley.com/doi/10.1111/j.1475-6773.2006.00564.x/full

[10] February, 2010 issue: http://journals.lww.com/pccmjournal/Abstract/2010/09000/Reducing_catheter_associated_bloodstream.5.aspx

[11] “Save 100,000 Lives” Campaign: http://www.ihi.org/IHI/Programs/Campaign/Campaign.htm?TabId=6#TheFirstCampaignInitiative

[12] worse than the worst rate at the worst big public men’s room in the United States: https://thehealthcareblog.com/the_health_care_blog/2010/09/nyc-train-station-bathroom-yields-cleaner-hands-than-hospitals.html

[13] Catholic health systems: http://www.catholicnews.com/data/stories/cns/1003243.htm

[14] articles: http://www.ascensionhealth.org/index.php?option=com_content&view=article&id=26&Itemid=139

[15] publicize hospitals’ safety records: http://www.govhealthit.com/newsitem.aspx?nid=75167

Michael Millenson is a Highland Park, IL-based consultant, a visiting scholar at the Kellogg School of Management and the author of “Demanding Medical Excellence: Doctors and Accountability in the Information Age”.

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  1. I had the exact opposite exrepience with TriCare mental health. I followed TriCares criteria for getting a referral and I had no problems with them getting payment. I also had to pay a copay that was significant, but I ddin’t havbe to pay full boat; I was able to afford monthly payments to the Doc. This was for a family member, not myself, the service member. I imagine some of the hate on TriCare in the article is because they doesn’t pick up the tab completely.If a psych don’t want to take tricare, it’s because their billing person is lazy, or they are more about money than helping people.

  2. Each major referral siophtal and its associated siophtals should have its own board. In other instances, a small cluster of siophtals could come under a board. Boards should not include more than one major referral siophtal. Details of which siophtals would fall under which local boards will be worked out with the States and local communities.So that is in fact much less than 737 boards controlling groups of siophtals! Far less dramatic and perhaps in practice not unlike what NSW is (and presumably other States will be) doing with the proposed introduction of Local Health Networks under the Government’s health plan. No bureaucracy gone mad in either case, but effectively a return by both to the Area Health Service structures of less than a decade ago.As to incentives, neither the Government’s nor the Opposition’s proposals will change the case-mix driven budgetary strictures that currently apply to siophtals and Area Health Services.

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  4. Cory,I must disagree with your assertions of the number of of deaths of HAI’s ( Hospital Acquired Infections) are far fewer than 99,000 people: When these satistics come from the CDC!
    I also will suggest that the numbers are far Greater than what the CDC had reported. However, I believe that many studies provided by the Health Industry are largely manipulated to site the industries consensus on the subject. The truth be known would be such a egregious number that the Headlines would drive deep fears into the heart of all patients. Still,we are only receiving voluntary reporting of StaPh infections.Most of which, have been purposely cherried picked.
    As a effort to limit possible negative event reporting. Our Hospitals have lobbied state legislatures and used the colloberative influences of State Departments of Health and Medical Boards to water down progress on Public reporting and transparency.
    Its not ok if you wish to stand on dated science or the lack of comprehensive studies on the matter. The truth is the industry has refused to actively track HAI’s. Let alone Medical Errors!
    Lets set aside your privledged Medical Journals and Insurance studies that are not accessable to public review. Lets take a look at a industry that refuses to act responsible in heading off”PREVENTABLE” infections and Medical Errors. Did you Remember the word in quotes? Oh Darn,Not again! The word to remember is……. PRE…..Vent…Able. Now lets try it again… “Preventable”. Yes, Now you have it!!
    It may be difficult to believe that the institutions that save lives actually take lives as well. It is not because they had no choice or exhausted all resources. To the contrary;they willfully ignored,”Preventable” and proven measures to protect patients. Best Practices that have proven to save lives!
    So defend that position and then reflect on the Needless Deaths of people who trusted their Health Care Workers.

  5. In our work with healthcare providers, I estimate that less than 20 percent are equipped with the tools necessary to improve patient safety in a standardized way. Physicians, nurses, pharmacists, etc., are not trained in the science of quality improvement. Furthermore, most health care organizations are not equipped to deliver the on-the-job quality training: even their in-house quality improvement departments are grossly under-resourced. What’s the solution? We must look to those health care organizations that make quality and safety a priority from the top down, and who have built the capacity and capability to train staff.

  6. It is interesting how when a problem is small it can be ignored, when it is bigger it is often hid and only when it it too big to be ignored and hidden is it really addressed. This would be a good time to address these problems.

  7. Speaking of computers, a new study out in the December issue of the Archives of Pediatric & Adolescent Medicine notes that only 18 percent of pediatric hospitals responding to a survey had a basic EHR system and only 3 percent had a “comprehensive” one. Financial barriers (capital need) and financial incentives (reimbursement) were cited as hindering or helping adoption.

  8. “I’ve used small claims court a couple of times representing myself and won and I sued my local county government in Superior court acting as my own lawyer and won that case as well…”
    Your point to challenge my opinion of you? I think you defended it rather nicely for me, thank you.
    Just as a lawyer would do?

  9. “I think after reading the latest comment by Peter, I am now convinced he is a rep for the legal profession,”
    I hate lawyers and think most are scum. They run a bigger cartel than doctors, but if you needed legal representation who would you go to? Even you would go to a lawyer Determined and I think launch a lawsuit if you thought you were harmed. I’ve used small claims court a couple of times representing myself and won and I sued my local county government in Superior court acting as my own lawyer and won that case as well, but complicated cases such as medmal need experienced lawyers and wouldn’t anyone choose the attach dog lawyer they thought could win for them.
    BTW, I don’t hate doctors, I just hold them to very high standards, higher than their profession should hold them and higher than most docs I’ve needed hold themselves.

  10. If the nurse is at the computer, she/he is not with the patient. Computers distract and degrade care.

  11. I think after reading the latest comment by Peter, I am now convinced he is a rep for the legal profession, and just comments here to stoke the fires for malpractice litigation. So, come clean, sir. Every negative outcome is not a lawsuit waiting to happen.
    The way you advocate, sir, who is going to save you or your friends WHEN you or they have medical problems? Who would want to should they find out what your agendas are: save me or anyone I associate with, and do so without any complications, or I’ll sue your ass into oblivion.
    Now there is a health care solution!
    Typical black and white thinking of the law!!!

  12. @Peter:
    YOU brought up the idea of a lawsuit in the context of the catheter infection issue, which is a nosocomial one:
    “”Those harmed were tended to by dedicated staff who thought they were doing everything they could to help the kids in their care. They were dead wrong, but even today they may not know it.” “four out of 10 U.S. hospitals still declined to participate.”
    rbar, a good lawsuit would bring these hospitals up to speed on patient safety. ”
    I am not a legal expert, but to my best knowledge, there is no mechanism to sue for malpractice because you feel (correctly or incorrectly) that they are not up to snuff re. safety. It is an “injured/damaged” ndividual that has to be the plaintiffn, and that victim has to prove to a jury that he/she was harmed by an identifiable negligent act. If a doc (or a nurse, PT etc.) failed with hand hygiene once or several times, that MIGHT have been the source of a harmful nosocomial infection, but it’s impossible to prove.
    And if you read my previous posts, my problem with litigation is mostly the “diagnostic failure” lawsuits, which are the single most frequent kind. Errors of judgment or recognition will happen because medicine is much more complex, unpredictable and ambiguous than, say, aviation engineering or law. If you don’t want docs to order all kinds of stuff to cover their asses, you have to protect reasonable judgment calls and even (what looks in moday morning quarterbacking like) oversights.
    @Mr. Millenson:
    I don’t think you have really explained the discrepancy I pointed out – or does the Milliman study cover only a limited cohort? Didn’t seem that way when I looked at the summary …
    In general, one big problem with all these numbers is that they are based on retrospective chart review:
    http://jama.ama-assn.org/content/286/4/415.full?sid=adbb993a-913c-4c03-87fe-258272029e20
    I am willing to change my mind on that if I hear convincing arguments, but the counterarguments plus implausible numbers make me think that the IOM estimates are way too high.

  13. “Peter, I sympathize with the goals of your lawsuit idea … but I don’t think the idea is grounded in reality since with the current system, you have to prove to individually have suffered demonstrably from a negligent act. That is probably impossible to do with a nosocomial infection.”
    rbar, is all we’re talking about here “nosocomial infection? That’s not what I read:
    http://www.nytimes.com/2010/11/25/health/research/25patient.html?_r=2&scp=1&sq=safety%20hospital&st=cse
    Did you read something different? And besides, if that is the case, “impossible to prove”, then why do you contend docs need safe harbor from law suits? Do you want security from those events that ARE possible to prove?

  14. The numbers:
    Milliman looked at insurance claims from private insurers. The Landrigan study in NC (just published in NEJM), the Harvard study (primary, but not sole basis for IOM) and the Mills study all used actual chart review of all patients. The Mill study, at least, looked at whether iatrogenic deaths were likely to have been among patients who would have died soon anyway; that was overwhelmingly not the case.
    OIG HHS study that appeared earlier in November was for Medicare patients only.
    The 100,000 number is really not thrown around for political effect. Almost everyone I see goes “up to…” The real stunner should be that this is PREVENTABLE medical error in hospitals alone. It’s not a matter of “one death is too many,” it’s a matter of at a low end we are killing, preventably, roughly 10 patients a year at every hospital. Make it one patient a month.
    The other test of credibility is this: if different studies by individuals with different motives and different approaches tend to find the same degree of harm over time, that’s an indicator that those who believe there is an enormous amount of preventable harm are correct. Moreover, while I’ve often heard physicians scoff at these numbers. I’ve rarely heard a nurse or pharmacist do so. That’s also an “in the trenches” reality test.

  15. Of course the numbers do matter if someone is claiming that the medical system kills 100 K people per year – yes, 1 K is enough to call for considerable effort, but it’s not disaster on an epic scale. And I do agree that patient safety can and should be improved.
    I wonder whether this number is touted as symptom of the “academic relevance boosting” syndrome. Whatever the issue one is writing/specializing about, one starts by painting the darkest possible picture of the impact of the problem at hand. But again, I don’t want to give the impression that I want to belittle the problem.
    Mr. Millenson, I am not an expert on the literature, could you explain how the Actuaries/Milliman study with reported 2861 inpatient excess deaths in 2008 squares with 100 K as claimed by the IOM? Is the remainder killed on an outpatient basis, or am I misreading the stats?
    Peter, I sympathize with the goals of your lawsuit idea … but I don’t think the idea is grounded in reality since with the current system, you have to prove to individually have suffered demonstrably from a negligent act. That is probably impossible to do with a nosocomial infection.

  16. What I find most disturbing is the abundance of comments on how the stats for preventable death are the problem, rather then accepting that clearly we must do better.
    If providers would simply follow some of the more ‘basic’ evidence-based guidelines (hand washing, line care, imaging indications, pre-op abx…)we would significantly improve on the ‘harmed’ number whether its 100000 or 1000.

  17. In regard to the 100,000 number: first, it is 44,000 – 98,000 by the IOM. Second, if you look at a study by the Office of Inspector General of HHS in October of Medicare patients, by the Society of Actuaries (by Milliman) of insured population in April and virtually every other study, it comes up with numbers that are in that range.
    I admit they do not “feel” right. Which is the point of the post.
    As for DeterminedMD: sorry if you’re offended by the words. I understand. But let’s put it this way. If airline executives ignored evidence of preventability of crashes because they trusted their own good intentions, skills and those of their pilots, at what point, when crashes kept on happening, would your patience run out? We’re not talking anecdote here, we’re talking peer-reviewed medical literature, and the evidence is overwhelming.
    But the evidence is very uncomfortable, so we fail to act.

  18. I think the title of this post is just in poor taste. Don’t include me in this “we”, that is just an overgeneralization that does health care a tremendous disservice. Does the system fail at times? Yes. Does the system intentionally harm people? I hope that is answered with a resounding “NO”. Could we do better? Again, yes. But framing these problems as killing?
    Poor choice of words!!!

  19. I remember being shocked when I saw the “science” behind the 98,000 deaths a year estimate.
    They looked at at most a few hospitals in New York State for a period of one year in 1984 and took the results from that and extrapolated it to the entire country, and then used the same number for the next 2 decades.
    Is the science in this latest study any better?

  20. As published in the journal Pediatrics, a pediatric hosptial in Pittsburgh increased its death rate of babies by 2.5 fold after it deployed a commercial CPOE “safety” ordering system.

  21. “Those harmed were tended to by dedicated staff who thought they were doing everything they could to help the kids in their care. They were dead wrong, but even today they may not know it.” “four out of 10 U.S. hospitals still declined to participate.”
    rbar, a good lawsuit would bring these hospitals up to speed on patient safety. The information is easily accessible and out there, it’s not as this stuff hasn’t been invented yet. Are you claiming good intentioned ignorance as a defense?

  22. Most people assume that all DNA paternity tests are the same, and it doesn’t matter where you get your DNA test done. That could not be farther from the truth.Even if you are using an accredited DNA paternity testing laboratory, the minimum required levels of paternity testing are very low. DNA paternity testing laboratories know that if they only test DNA to the minimum required level, a number of paternity test results every year will identify someone as the biological father when he is not (a “false inclusion”) or say that he is not the biological father when he actually is (a “false exclusion”).

  23. Excellent post! Similar premise and call to action with Gawande’s landmark ‘Checklist Manifesto’, also excellent. As a full-time primary care doc having worked in ER, clinics, and hospitals, I often say lately that if the public knew what really goes on in healthcare, there would be riots and picketing in the streets. From similar concerns to those in this post (same principles apply to the standards-lacking, hodge-podge we call primary care) I am an activist in health information technology and policy. It’s high time we docs admit the emperor has no clothes and rebuild the system; and we will have no better time than now to do so. Widespread HIT is absolutely essential to doing so in our modern healthcare reality; but a new approach to quality of care in general must also arise…the fact that thousands of people fly busy skies every day, and months go by with no significant crashes of airliners proves that complex systems CAN be operated safely; long overdue in medicine, and a veritable shame that we allow the current state of things to continue. Gawande, Millenson, and others are writing to expose these problems; now let’s address them…NOW. Premium non nocere…

  24. Peter, I don’t know what you want to prove to me. Let me copy from my own post just above: “I agree with most of the OP. Patient safety needs to improve, and some of the examples (e.g. PICC line policy study, handwashing frequency) are a shame to our profession.”

  25. rbar, can’t copy the entire thing but:
    “Now fast-forward to the February, 2010 issue [10] of Pediatrics, in which the collaborative concluded: “CA-BSIs are a preventable cause of patient harm to critically ill children.” What you can’t see in the peer-reviewed literature is this context: at literally scores of hospitals which declined to participate in the collaborative, hundreds of sick children likely were injured or killed who probably would not have been harmed had the hospital been a collaborative member. Those harmed were tended to by dedicated staff who thought they were doing everything they could to help the kids in their care. They were dead wrong, but even today they may not know it. Certainly, their patients and the public do not.
    I’ll cite just two other examples of inertia and invisibility interacting to impede change. When the Institute for Healthcare Improvement launched its “Save 100,000 Lives” Campaign [11] on the fifth anniversary of the IOM report (the delay speaks for itself), four out of 10 U.S. hospitals still declined to participate. No policymakers or commentators questioned why 40 percent of hospitals would sit out this opportunity to improve care.
    Another example: the Centers for Disease Control and Prevention published its first hand-washing guidelines in 1975. Yet nearly 35 years later, when the Joint Commission launched an improving hand hygiene project, the eight hospitals that volunteered had a baseline hand hygiene rate typical of hospitals nationwide: 48 percent. That’s worse than the worst rate at the worst big public men’s room in the United States [12], according to one recent survey. But rather than giving providers an ultimatum, we launch campaigns to ask patients to ask providers to please wash up.”
    Where is the “inadvertent harm”?

  26. Agree with Stenes. $ millions being spent and nothing to show for the HIT deluge. Increasing neglect, increasing costs, no reduction of errors, more deaths from the neglect.
    Transparency please on the HIT. These devices need vetting and oversight. Hey Landrigan, how did the wired hospitals do??

  27. @Dr. Stenes –
    “The Landrigan study was flawed in its failure to show that the 4 miilions of hIT devices in some of the hospitals did NOTHING, or promoted more errors of the ilk he describes.”
    ___
    OK, are we to assume that YOU, though, are privy to such documentably damning findings? That, paper documentation, net, is safer?

  28. Sorry – without commenting one way or another on the safety issue, the “100,000 deaths from error figure” is implausibly wrong. It has never been validated by any type of prospective analysis, it relies totally on extrapolation and makes little sense. It would mean an average of 2000 deaths by error in each state each year. That would be nearly six deaths in every state every day. You’d be hearing about that plenty from all sorts of sources.
    You mean to say that wouldn’t be documented in some fashion with malpractice suits, journalism exposes, insurance analyses, M and M conferences at hospitals? No way. virtually impossible.
    the definition of error is way too broad and the cause and effect relationship is way too tight.
    Look there are about 2.5 million deaths every year in the US. a quarter of a million are due to suicides, accidents and homicides- it’s logical to assume at least another couple hundred thousand, perhaps more, don’t occur in hospitals (cardiac sudden deaths and the like). so the universe of all possible deaths due to error is almost certainly less than 2 million. All deaths.
    Someone is saying that 5% of all these deaths, perhaps higher, – people with terminal disease and every one else, are caused by error? Again virtually impossible to be happening without it being obvious thru outside channels.You don’t realize what a huge number that is.
    Four points –
    1.thousands of people may die from errors each year depending on the definition, perhaps tens of thousands, but not 100,000 and probably not close to 100,000, even with a liberal definition.
    2. No one has been able to verify this and in fact several commentators have called the number into question. Brennan one of the main authors of the paper that originated it and that the IOM used, had earlier used an ever higher number pulled from where?, at a time when there were fewer deaths in the United States. Even this now commonly cited figure of 100,000 is above the actual range of the source (44-98,000). The number has no independent validity whatsoever.
    3.The same type of extrapolation led to the figure of 600,000 deaths in the first three years of the Iraq War, published in Lancet. Again same type of thing- didn’t pass the smell test. 600,000 deaths would have meant 200,000 per year or nearly 600 people dying every day. A particularly gruesome battle or car bomb might kill 50-100 and be reported extensively, to expect 5-10 times that number dying every single day for three years going unreported defies belief. Turns out when they actually analyze the figures, the numbers are actually 1/5-1/4 quarter of that. That’s plausible.
    4. This is not in any way a commentary on safety issues. It is a commentary on death reporting and death statistics. I doubt if one doctor, nurse or administrator in 50 can even cite accurately the actual number of deaths in their hospital /year. So they don’t know how many people are even dying and they can say that 5% are dying of errors. unbelievable- and no independent backup to make us believe it. Amazing for a group as “scientific” as the IOM to continually use such an unverified statistic that is likely “in error” itself

  29. I agree with most of the OP. Patient safety needs to improve, and some of the examples (e.g. PICC line policy study, handwashing frequency) are a shame to our profession.
    BUT:
    The IOM numbers have become conventional wisdom, even though there is very solid criticism of these numbers, which I personally think are completely off the wall. In the past, I provided a link, but I am getting tired. These numbers come up, again and again, like Fox news claiming that the mainstream media are “liberal”.
    Peter, you had an interesting discussion with Dr. “Quack” Vickstrom a few days ago? Honestly, did you learn anything new from that discussion? Moreover, do you think there is significance that you overread (or chose to ignore) the following passage: “and only a small proportion represent negligence. This is inadvertent harm; there are no villains here.”?

  30. There is another “I”, making four, with the fourth one enabling more of the first three. Drum roll___IT, or health IT. The Landrigan study was flawed in its failure to show that the 4 miilions of hIT devices in some of the hospitals did NOTHING, or promoted more errors of the ilk he describes.
    I remain shocked at Landrigan’s omission of the role of hIT and how it adds to the invisibility, inertia and income with pages of cut and paste, small fonted meaningfully useless information.

  31. “The first large-scale study [2] of hospital safety in a decade concluded that care has not gotten significantly safer since the Institute of Medicine’s 1999 estimate [3] of up to 98,000 preventable deaths and 1 million preventable injuries annually.”
    And docs want safe harbor from malpractice suits – yea, that’ll work.

  32. My father went to a private hospital in Brooklyn, New York because he had been depressed after the death of my mother a year and a half earlier so he did not eat for a couple of days. The hospital against my will decided to give him a bunch of anti-depression drugs and he wind up having so many complications from pneumonia, stroke, blood thinning problems and suppossedly a heart attack. My dad died alone with me living 10 minutes away as the hospital never called me that day. As my father was in his late 70s they claimed its natural causes. I feel the hospital got away with murder. When I asked for medical records, they took 2 months to get them to me after charging an arm and a leg and those records look like they were altered. I hope the doctors who killed my dad can sleep at night. No one from the hospital ever addressed what happened to my dad. When I asked the attending why nI was not called even though on the charge it says to call me asap if there is a change, he said DID YOU WANT US TO DROP EVERY THING AND CALL YOU? I arrived to visit my dad 16 minutes after he had died.

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