Hospitals

Actually, Medical Errors are the Leading Cause of Death

flying cadeuciiJosef Stalin famously said: one death is a tragedy; one million is a statistic. Perhaps 250, 000 preventable deaths from medical errors, according to an analysis by Makary and Daniel in the BMJ, maketh a Stalin.

The problem with Makary’s analysis, which also concluded that medical errors are the third leading cause of death, isn’t the method. Yes, the method is shaky. It projects medical errors from a series of thirty five patients to a country of 320 million, which is like deciding national spice tolerance on what my family eats for dinner.

The problem with Makary’s analysis isn’t that it is full of assumptions. Assumptions are inevitable in biomedical research, and abundant in health services research. Researchers of medical errors must determine whether a bad patient outcome, such as death, was avoidable. Bad outcomes lie in a spectrum between inevitability and preventability. If every death is inevitable doctors are rendered impotent, and if every death is avoidable doctors are rendered omnipotent (FWIW, I prefer omnipotence).

Researchers of medical errors don’t have perfect information. They don’t know the clinical context. How can they? They were not there. They must assume and set their default assumption – which means that the researchers must choose between erring towards calling a bad medical outcome avoidable or inevitable. Err they will. But if they must err in their adjudicating error they must err systematically, because the scientific method, the measuring instrument, demands consistency. Even though reality is arbitrary, stuck between reality and science, the researchers are compelled to choose science.

Systematic erring by a measuring instrument scales the error it makes. Yet, the problem with Makary’s analysis isn’t the estimation of deaths attributable to medical errors. Yes, 250,000 deaths a year from medical errors is alarming – that is 28 deaths an hour, or a death every two minutes. At their most murderous, ISIS decapitated 28 Ethiopian Christians along a beach in Libya in one morning.

I’m not attempting dark humor by conflating ISIS and medical errors. I would not jest without observing that patients are not flocking to Palmyra in the arms of ISIS – the lesser of the two quantitative evils – to escape hospitals. I’m pointing out – I hope successfully to the satirically challenged – the absurdity of using morally relativistic hyperbole to convey the gravity of medical errors.

If it wasn’t emotive enough comparing the toll of medical errors to a jumbo jet crashing daily after the Institute of Medicine (IOM) report, To Err is Human, medical errors have been likened to serial urban genocide, and even the holocaust. Metaphors and similes can literally be dangerous with people who are literal. And it’s unclear that those who resort to hyperbole aren’t being literal.

Unmoored quantitative reasoning places rationality absurdly close to stupidity leading to egalitarianism of death – stripping death of context – giving a resident who ruptures the aorta from a misguided intra-aortic balloon pump insertion the same moral vector as Jihadi John making snuff movies.

Hyperbole is seldom helpful. Hyperbole creates resentment in patients who have been harmed, which surely isn’t the intent. But hyperbole also tunes out doctors because the comparisons are so egregious that they becomes parody. Medical errors lose gravity precisely because overzealous safety advocates elevate them to a frightening level of quantitative seriousness, even though the intent of hyperbole may be to receive more funding from the public purse, rather than to demonize physicians.

Makary’s numbers may well be very bad numbers, but if the number of preventable deaths is 25, 000 a year – how would things be done differently? Would you say – “that’s a preventable death every twenty not two minutes. Thank God”?  Which takes me to the problem with Makary’s analysis. The analysis is problematic not because it is wrong. In a sense it is not even wrong. It is problematic because of what it implies.

Makary’s analysis, indeed other analyses of medical errors, implies that death is an anomaly. That once the doctor intervenes, death is optional. At what point death ceases to be deferrable is anyone’s guess. So when physicians fight death until the patient’s last breath – the cause of much indignity in people’s last week on this planet – it is because we (doctors and patients) think death is abnormal.

The authors narrate a case in which the patient post-transplant died from a bleeding hepatic pseudoaneurysm because of a pericardiocentesis which breached the liver. Was not this an error? Should the cause of death not be medical error? The answer is yes, in a Newtonian sense. But the structural assumptions and corollaries of this conclusion lie in a Twilight Zone where profundity and parody coexist.

If medical errors are causative, if medical errors are a disease, if the American hospital is the most dangerous place on earth after Hotel Rwanda, then it follows that a sensible precautionary measure to avert this dangerous entity is to abstain from it and let nature take its course. Contradictions are replete in the Twilight Zone.

The IOM estimated that 98, 000 deaths were attributable to medical errors – Makary’s estimate is over twice that, one analysis says it may be ten times. What is going on, Have doctors become more ten times more incompetent? Given the billions spent on quality and safety how is it we suck even more today? Were hospitals safer in 1950 than 2016? Is the intensive care unit the greatest scourge on mankind since syphilis? Is the balloon pump a proxy of danger – like a Kalashnikov – or does it signal something else?

The greatest paradox of medicine is that the more lives it saves the more responsible it becomes for not saving lives. The sicker and frailer the patient, the more invasive lines and tubes they have, the more likely they are to benefit from the intensity of treatment, and the more at-risk they are to medical error. You’re at greatest risk from medical error when you have most to lose from no medical care. At death’s door medicine is both your friend and foe. Antibiotics can save you from death from sepsis or kill you from toxic megacolon from pseudomembranous colitis. The antibiotic is both Florence Nightingale and Chengiz Khan. It is our failure that we have not articulated this paradox to the public at large.

The goals of the safety movement are noble. There are serious medical errors and seriously incompetent doctors. But collapsing all errors, regardless of the degree of seriousness or preventability, to integers to enable easy arithmetic is injustice to those who have truly been harmed. Doctors should certainly strive to be better. But better is an aspiration. And to make doctors better, and healthcare safer, it surely is better encouraging professional pride than inducing professional guilt.

To be fair, I can’t single out the safety movement for moral relativism of death. Egalitarianism of death is the zeitgeist – after all, a death is a death, isn’t it? The excess deaths from flecainide post myocardial infarction, before CAST put that practice to rest, has been quantitatively likened to the Vietnam War.

“Dying” and “saving lives” have lost all meaning. Republican Governors were accused of causing death by not expanding Medicaid. By which logic, the FDA are mass murderers every day they delay approval of life-saving drugs, and 20 % (i.e. the relative risk reduction of screening) of women who die from breast cancer for skipping mammograms because they listened to the USPSTF’s recommendations should put cause of death: USPSTF. And denying statins to an expanded constituency of 33 million Americans, assuming an NNT of 100, kills 37 people an hour, putting ISIS to quantitative shame.

There’s no moral distinction between death from action and death from inaction. Chengiz Khan stared at his victims before chopping their heads. With statistical deaths neither the murderers nor their victims know each other.

I’ll leave future anthropologists to explain how Homo sapiens at the zenith of rationality lost the plot. For now I must my express my strongest objection to Makary’s analysis. He says that medical errors are the third leading cause of death. I disagree. Given the optionality of death, the inevitability of death, and the omnipotence of physicians, medical errors are surely the number one cause of death.

About the author:

Saurabh Jha is a radiologist and a contributing editor of Healthcare Blog. He can be reached on Twitter @RogueRad

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Categories: Hospitals, THCB

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larrywpPerryWilliam Palmer MDBarry CarolLaurie Gordon Recent comment authors
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larrywp
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larrywp

You have misinterpreted the data in that article completely. The number you quote is a base statistic. There were at least 180,000 deaths in 2016 from Medicare patients alone; and you are not extrapolating accurately. The actual number of deaths from preventable medical error is approximately 440,000; and the number of patients that suffer “serious harm” due to preventable medical error is between 4.5 and 9 million. Get your facts right. But there’s little else I can expect from a physician.

Perry
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Perry

And the lesson is:
Stay away from doctors and hospitals.

William Palmer MD
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William Palmer MD

These scolds need to get some attorney friends. The law has been dealing with this negligence problem for hundreds of years. It has come up with the concept of “proximate cause”. [my dad was a judge]. To find the proximate cause is the law’s way of assigning guilt or accountability when negligent or other wrongful actions are litigated. There may be other ways too. There are two parts: 1. You say “if not, but for ____( the action is put in here)______, this would not have happened.” 2. Then you say “given ____(this set of facts)___, we can predict a… Read more »

Peter
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Peter

“These scolds need to get some attorney friends.”

Not sure which side you’re on?

Nortin Hadler
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Nortin Hadler

We visited this issue last fall before Makary tortured these data, again. That post and the discussion that followed remains highly relevant:
https://thehealthcareblog.com/blog/2015/10/15/medical-errors-or-not/

Pesto Sauce
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Pesto Sauce

I agree that the subtext of the study is that death is optional, and that we are incompetent idiots who can’t manage a single patient without killing them–esp. a volume overloaded kidney transplant patient in rejection who is alive by the very interventions that can easily cause death. The patient would have died on Serengeti centuries ago. The problem is that as a society, we don’t know when to stop with the interventions. The more interventions, the more chance for an inadvertent error. “Do everything you can doctor to save the life!!!”. I asked the chief cardiologist “why are we… Read more »

Peter
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Peter

“The problem is that as a society, we don’t know when to stop with the interventions.”

Pesto, what criteria would you tell “society” to follow?

Barry Carol
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Barry Carol

I would tell U.S. “society” to replicate the Western European cultural mentality of not imposing unreasonable costs and expectations on their fellow citizens especially with respect to end of life care. For good measure, their less litigious tort environment would be worth emulating as well if we want to lower healthcare costs or at least slow its growth rate.

Peter
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Peter

“I would tell U.S. “society”…”

U.S. society doesn’t like to be told.

Pesto Sauce
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Pesto Sauce

No society should ever be “told”, the author starts out with a quote by Stalin, and look how well that went…I have observed that economics more than anything else shapes behavior. The insane spending during the last few months of life, by Medicare, is what I’ll stick to since it’s what I see as a physician. Everybody gets the full court press at death unless there are living will witnesses, DNR/DNI orders, and/or intelligent communication. No, your 96 year old demented mom is dying and she will not get dialysis for life ( 1 week). The baby boomers’ parents are… Read more »

Peter
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Peter

“and they would direct their own care according to their means.”

So wealthy people get the full court press and poor people are told they don’t have the money to prolong care?

“immediate tort immunity”

Interesting comment in a topic on medical errors.

“I say, we sorely need end of life, SANE discussions on this topic.”

Yes, but convince the “christian reich” on that. How about an economic incentive to create a living will. What if the will says – “spare no money to keep me alive”?

Pesto Sauce
Member
Pesto Sauce

A will can say “spare no expense”, but the procedure party would go on until the money runs out. No heir will go bankrupt caring for Mom. The more interventions, the more chance for errors, it’s a cumulative add-on effect. And it’s a situation of damned if you DO (to cover the legal ass) and damned if you DON’T (to cover the legal ass again) so tort immunity in caring for government insured persons would eliminate a substantial chunk of cash. Make no mistake, the defensive medicine costs are huge and never discussed because the attorneys themselves wrote PPACA, so… Read more »

Peter
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Peter

“Or you can go to the county hospital where you’re at risk for MRSA and see vomit stains on the curtain separating you from the other (combative) patient.” Is that where you’d want your mother to go? “I do see more hospice advocacy locally” Medicare pays for hospice. “and doctors can tell when it’s the end–are inhumane” Do you prompt your other docs to have the end-of-life talk? Does your hospital have a policy on this? How do you fight for this? At my wife’s hospital the docs DO have the reality talk to parents of hopeless premies. I don’t… Read more »

Pesto Sauce
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Pesto Sauce

Some hospitals “encourage” end-of -life talks, most don’t because the more procedures, the more they make from Medicare and Medicaid, hence a big conflict of interest. As a private individual of course I discuss with colleagues, some agree, some don’t. I can’t force others what to do or say, no more than you. The wealthy eat up more of everything, simply because they have money. Accept that and you’ll be able to engage in debate, no matter what your belief is. I’m offering creative ideas to the tangled mess of excessive interventions, excessive errors, waste of money, OUR money, federal… Read more »

Peter
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Peter

“The wealthy eat up more of everything, simply because they have money. Accept that and you’ll be able to engage in debate” Health care is not cars, houses or gourmet restaurants. As soon as you separate the richer folks from the health care system the poorer folks get ever increasing marginalized, underfunded care. If we can unify on something it should be health care. I’m not arguing that EOL care is expensive and usually unnecessary, it is also for the wealthy. I just think we need a better way to get people to create living wills, if you can fight… Read more »

Barry Carol
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Barry Carol

Peter — Maybe suggest is a better word that told.

Pesto Sauce — In your experience, what percentage of Medicare patients get the full court press at the end of life and has it changed any over the last 5-10 years? Do you think it will change in the future in the absence of other changes in the system?

whynobodybeliev
Member

It isn’t just the deaths. The #1 primary coded ICD9 has been “sepsis.” By a considerable margin over #2. Obviously, not all sepsis originates in the hospital, by a longshot–but there are also plenty of sepsis cases that are not primary-coded if they are coded at all, and plenty of errors that are not sepsis.

Still for sepsis to be #1 and no one has commented on this, is huge. Obviously this is a big problem.

Peter
Member
Peter

You’re missing Makary’s larger point if you focus on the numbers to discredit him. “Currently, deaths caused by errors are unmeasured and discussions about prevention occur in limited and confidential forums, such as a hospital’s internal root cause analysis committee or a department’s morbidity and mortality conference. These forums review only a fraction of detected adverse events and the lessons learnt are not disseminated beyond the institution or department.” Nurse accidentally kicked the respirator cord out of the socket – cause of death on death certificate was respiratory failure. Not listed as a medical error. I listened to a discussion… Read more »

Pesto Sauce
Member
Pesto Sauce

Respirators are very difficult to accidentally unplug with your foot–have you done this with your TV when it’s on? Or washing machine? Same gigantic machine with the rear to the wall and all the digital setting in front where they can be seen. Also, that would be a NURSING error, not a medical error. Whoever makes the mistake owns it. But isn’t someone on a respirator, by definition, being kept alive artificially? We have legions of people living longer but with zero quality of life. Facilities full of demented vegetables. In France they start the sublingual morphine when the shortness… Read more »