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Health August 2014

Aid for Age

Advocate for Your Own Health to Bring Down Avoidable Hospital Deaths

By Tait Trussell

A new report by the U.S. Department of Health & Human Services (HHS) concluded only one in seven medical errors involving Medicare patients ever actually comes to light. Inspector General Daniel R. Levinson observed that even when errors are reported, practices are rarely changed to avoid an encore performance.

A new study reveals that each year preventable adverse events (PAEs) lead to the death of 210,000-400,000 patients who seek care at a hospital. Those figures make medical errors the third leading cause of death after heart disease and cancer, according to the Centers for Disease Control and Prevention (CDC) The following are the list of leading death causes in the U. S., according to the CDC.

  • Heart disease: 597,689
  • Cancer: 574,743
  • Chronic lower respiratory diseases: 138,080
  • Stroke (cerebrovascular diseases): 129,476
  • Accidents (unintentional injuries): 120,859
  • Alzheimer's disease: 83,494
  • Diabetes: 69,071
  • Nephritis, nephrotic syndrome, and nephrosis: 50,476
  • Influenza and pneumonia: 50,097

The new study reveals that each year preventable adverse events lead to the death of as many as 400,000 patients in hospitals. The latest findings are based on research conducted by John T. James, Ph.D., who oversees the advocacy group Patient Safety America, an organization he founded in honor of his 19-year-old son who died in 2002 as the result of what he described as negligent hospital care.

James analyzed four recent studies that flagged specific evidence in medical errors, such as medication stop orders or abnormal laboratory results, which point to an adverse event that may have harmed a patient.

A physician must concur on these adverse event findings before they classify the severity of patient harm. Based on the weighted average of four studies, he concluded that at least 210,000 deaths are due to preventable harm in hospitals.

But because of the limitations of the tool and incomplete medical records, he wrote that the number is likely twice that figure, more than 400,000 deaths each year.

"There was much debate after the report about the accuracy of its estimates," James wrote in the study. "In a sense, it does not matter whether the deaths of 100,000, 200,000 or 400,000 Americans each year are associated with PAEs in hospitals. Any of the estimates demands assertive action on the part of providers, legislators and people who will one day become patients."

The problem, James said, is that action and progress on patient safety has been slow. He wrote that he hoped these latest evidence-based estimates of 400,000 patient deaths each year will foster an "outcry for overdue changes and increased vigilance in medical care to address the problem of harm to patients who come to a hospital seeking only to be healed."

Lucian Leape, M.D., who served on the committee that wrote the "To Err Is Human Report," told ProPublica that he believes James' estimate is accurate. He said the committee knew at the time of a 1999 study that the numbers were low.

"It was based on a rather crude method compared to what we do now," Leape told ProPublica. Furthermore, he said, medicine is more complex now, which leads to more mistakes.

Errors may occur because of holes in the system. For instance, at Phillips Eye Institute in Minneapolis, surgeons used to bring all of their lenses for the day into an operating room and stack them in order. But if one patient canceled, the order of lenses would remain the same, which resulted in patients receiving the incorrect implant.

The New York Times recently reported about surgeons and other staff responding to emails and texts while making rounds and even during surgeries. We already know how dangerous it is to use mobile devices while driving; that it's occurring during far more complicated tasks is inexcusable. It's a simple policy change to ban the use of all electronic devices for personal use while on hospital property and not on a work break unless it's an emergency – and during procedures entirely. If patient care is an imperative, everything else is not.

Patients are particularly vulnerable to errors during shift changes, according to Mike Smith, a personal injury attorney in Arkansas. Known as the "portfolio effect" phenomenon, the early cases on the list get more attention than the last cases. When providers are rushing, the patients at the end may be shortchanged. Smith encourages providers to use a shift-change model from Massachusetts General Hospital, in which sicker patients get the most attention. Shift change and charting begins with the most acute patients and works down to less severe cases.

The Institute for Safe Medication Practices (ISMP), in Horsham, Pa., encourages interdisciplinary education to prevent errors, specifically for drug safety. According to the Institute, nearly three quarters (72 percent) of hospitals don't have nurses spending time in the pharmacy during orientation, and nearly half (47 percent) don't include pharmacists on medical staff orientation, Pharmacy Practice News reported. And about a third (34 percent) of hospitals don't assign new staff pharmacists to patient-care unit training.

A new report by the U.S. Department of Health & Human Services (HHS) concluded only one in seven medical errors involving Medicare patients ever actually comes to light. Inspector General Daniel R. Levinson observed that even when errors are reported, practices are rarely changed to avoid an encore performance.

Reducing rather than ignoring errors is a no-brainer for finance executives, as they cost hospitals huge sums of money. A drug error costs about $4,000 on average. At least 1.5 million occur every year, and many of them kill patients. A retained surgical instrument usually costs tens of thousands of dollars to correct. Hospital-acquired infections don't count as errors per se, but given they can be virtually eliminated with some thoughtful planning, they might as well be.

The single most important way you can help to prevent errors is to be an active member of your health care team. That means taking part in every decision about your health care. Research shows that patients who are more involved with their care tend to get better results.

 

Tait Trussell is an old guy and fourth-generation professional journalist who writes extensively about aging issues among a myriad of diverse topics.

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