DEATH BY MEDICAL ERROR

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DEATH BYMEDICAL ERROR
THE HIDDEN EPIDEMIC
2

• By
• William Charney

Editor of Epidemic of Medical Errors and
Hospital-Acquired Infections
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What does the term Medical Error mean?

• A combination of medical errors where doctors,
  nurses or health care workers make mistakes
• Medical errors
• Health care acquired infections
• Misdiagnoses
• Medication errors
• Surgical errors that produce fatality or
  morbidity
• Blood clots
• Hospital-acquired uncontrollable diarrheas
• Outpatient errors
• Nursing home errors

4
Medical Error leading cause of death to
Americans over 788,000 per year plus millions
of injuries

• Source Dr. Gary Null and Joe Graedon, MS, and
  Teresea Graedon, PhD, Top Screwups Doctors Make
  and How to Avoid Them

5
Medical Error 2nd leading cause of death
to Canadians approximately 56,517 to 63,098
deaths per year plus 552,473 adverse events
Source Extrapolation from Baker Report and the
Public Health Agency of Canada 
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Systemic causes of medical error have been built
into the design of the systems both in Canada and
U.S.
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Systemic Factors in Medical Error

• Profit Motive
• The Journal of General Internal Medicine
  published a study in March 2000, titled Hospital
  Ownership and Preventable Events. It showed
  that patients in for-profit hospitals are 2 to 4
  times more likely than patients at not-for-profit
  hospitals to suffer adverse events such as post
  surgical complications, delays in diagnosis, and
  treatment of an ailment.
• Source Vol. 15 No. 3 Pgs. 211-219

8
Factory Medicine in Canada

• Number of
• Patients per day
• Procedures per day
• Operations per hour
• Patients per minute
• Beds per region

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Systemic Factors in Medical Error (contd.)

• Staffing
• Patients in a hospital with a 18
  nurse-to-patient ratio, have a 31 greater risk
  of dying than patients in hospitals with a 14
  ratio.

• Only state with ratio regulation is California
• No Canadian province has ratio regulation

Source Aiken, et al JAMA 288 No. 16 (2002)
1987-92
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Systemic Factors in Medical Error (contd.)

• Shift Work
• Longer shifts translate into more errors.
  Physicians who are scheduled to work long hours
  make 36 more errors with 5 times as many serious
  diagnostic errors

Source Found in "Epidemic of Medical Error" CRC
Press, ed. Charney, Chapter 9 authored by
Pontus pp. 191
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Systemic Factors in Medical Error (contd.)

• Behavior
• A study of 1,700 nurses, physicians, clinical
  care staff and administrators found fewer than
  10 address behavior by colleagues that routinely
  includes trouble following directions, poor
  clinical judgment or taking dangerous shortcuts.
  Specifically, 84 of MDs and 62 of RNs and other
  clinical care providers had seen coworkers taking
  shortcuts that could be dangerous to
  patientsfewer than 10 said they directly
  confront their colleagues.

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Systemic Factors in Medical Error (contd.)

• Non and Under Reporting
• There are 27 states in the U.S. with reporting
  regulations
• Quebec is the only province in Canada that has
  reporting regulations
• 5 and no more than 20 of medical error
  incidents are reported

Source Leape, JAMA 1994, Dec. 21 272(23) 1851-7
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Systemic Factors in Medical Error (contd.)

• Working Conditions
• Poor working conditions, such as ergonomics,
  patient developmental flows, staffing, workload,
  scheduling, and autonomy contribute directly to
  medical errors. In 115 studies included in a
  2003 review, working conditions affect patient
  safety, the rate of medication errors, and the
  rate of recognition of such errors after they
  occur

Source Blum et al Natural Science Sleep 3 pp.
47-85
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Systemic Factors in Medical Error (contd.)

• Accountability
• Studies have shown even getting healthcare
  workers to wash hands between patients or after
  leaving bathrooms is not enforced and there are
  low compliance rates
• 52 of doctors did not wash their hands between
  patients

Source CDC, 2003
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Systemic Factors in Medical Error (contd.)

• Cost-Benefit Analysis
• The Society of Actuaries has stated that medical
  errors are costing 20 billion a year. Bedsores
  alone account for a cost of 3.9 billion
  annually. The cost per patient of medical error
  can be as high as 20,000 per bed (using the
  American Hospital Associations data of 1 million
  hospital beds in the U.S.)

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Systemic Factors in Medical Error (contd.)

• Injury to Workers
• Injury contributes systemically to medical error
  and compromises patient safety.
• Injuring a worker leads to a downstream negative
  patient effect.
• Source Charney and Schirmer, AAOHN Journal
  - American Association of Occupational Health
  Nurses Journal)

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Systemic Factors in Medical Error (contd.)

• Bullying
• Nurses reported that 71 of bullying behavior
  resulted in medical error of which 29 resulted
  in death

Source Rosenstein, et al. Joint Commission
Quality Patient Safety 34(8) 467-71
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Systemic Factors in Medical Error (contd.)

• Technology
• Reliance on technology is not a panacea for
  solving medical errors. Human factors still
  apply.
• Despite computerization of pharmaceutical
  approaches, 98,000 people per year end up in
  emergency rooms every year (mostly elderly) due
  to medication error.
• Source New York Times, 2012

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Organizations in charge of fixing medical errors
are organizations mostly responsible for creating
problems

• Patient advocacy groups and Canadian and American
  labor unions should lead the struggle to reform
  health care

•   

20
Organizations in charge of fixing medical errors
are organizations mostly responsible for creating
problems

• Patient advocacy groups and Canadian and American
  labor unions should lead the struggle to reform
  health care