Are medical mistakes common? A study from Johns Hopkins University titled “Medical Error–The Third Leading Cause of Death in the US” suggests that the answer to the question about medical mistakes is a resounding yes (BMJ, May 3, 2016). If anything, we believe their analysis provides a gross underestimate of the scope of the problem. This reader is a living example:
A Reader Describes Medical Mistakes:
“I’ve had a couple of medical misadventures in my life and a major misdiagnosis. I’ve also been the victim of a pharmaceutical error in which I was given a wrong prescription.
“Medical errors kill and injure more innocent people than the police but receive little attention by the news media. I’m a former newspaper reporter and editor. If the American news media become concerned about medical errors, we might see some improvement.”
Unfortunately, misdiagnoses, medical errors and pharmacy mistakes are far more common than people realize. Occasionally, a dramatic blunder gets attention, but the big picture doesn’t.
Dr. Martin Makary made headlines five years ago with an analysis showing that medical mistakes are the third leading cause of death in the US (BMJ, May, 2016). He received a lot of pushback from health professionals, but we reached a similar conclusion ourselves when we did the research for our book, Top Screwups Doctors Make and How to Avoid Them. If your library does not have a copy, you can find it in the books section of the store. We offer practical suggestions to help patients avoid both diagnostic errors and pharmacy mistakes.
One patient wrote:
“I was not misdiagnosed; I was totally ignored. I complained multiple times to my primary that I was having episodes of irregular heartbeat that caused exhaustion, shortness of breath and chest discomfort. I went for a physical at one point and told her I was having an episode. She didn’t even listen to my chest.
“I finally saw a cardiologist who diagnosed me with atrial fibrillation. He said the Afib could have killed me.”
The patient safety experts from Johns Hopkins reviewed the medical literature and noted that other estimates of preventable adverse events:
“…described an incidence range of 210,000-400,000 deaths a year associated with medical errors among hospital patients. We calculated a mean rate of death from medical error of 251,454 a year…We believe this understates the true incidence of death due to medical error because the studies cited rely on errors extractable in documented health records and include only inpatient deaths.”
Martin Makary, MD, the lead author of the analysis in the BMJ points out that doctors rarely mention medical errors as a cause of death on death certificates. As a result, the public knows very little about the number of people who die annually as a result of preventable mistakes.
The Tip of the Iceberg:
In our book, Top Screwups Doctors Make and How to Prevent Them, we analyzed the medical literature regarding health care harm. If we are even close to being correct in our estimates, treatment-attributable (iatrogenic) deaths are actually the leading cause of death in America by quite a margin.
Annotated Summary of Iatrogenic Deaths
“iat·ro·gen·ic adj \(ˌ)ī-ˌa-trə-ˈje-nik\: induced inadvertently by a physician or surgeon or by medical treatment or diagnostic procedures” (Merriam-Webster).
We are discussing treatment-attributable deaths. They differ from medical mistakes because there are many instances in which it is not possible to document responsibility. Nevertheless, iatrogenic mortality in health care settings as well as in the community is, in our opinion, the leading cause of death in the U.S.
Fatal Drug Reactions (in hospital): 106,000:
Range: 76,000 to 137,000. The mean is 106,000. Lazarou, et al. conclude:
“We estimated that in 1994 in the United States 106,000 (95% CI, 76,000-137,000) hospital patients died from an ADR [adverse drug reaction]. Thus, we deduced that ADRs may rank from the fourth to sixth leading cause of death.”
Lazarou, J., et al. “Incidence of Adverse Drug Reactions in Hospitalized Patients: A Meta-Analysis of Prospective Studies.” JAMA 1998; 279:1200-1205.
Fatal Drug Reactions (outpatient): 198,815
This number was derived from a computer model assessing complications of drug treatment in the U.S.
Johnson, J.A. and Bootman, J.L. “Drug-Related Morbidity and Mortality and the Economic Impact of Pharmaceutical Care.” American Journal of Health System Pharmacists 1997; 54:554-558. And Bootman, J.L. “Drug-Related Morbidity and Mortality: An Economic and Clinical Perspective.” Managed Care 2002; 11(2 Suppl.):12-15.
Fatal Drug Reactions (nursing homes): 41,652
There is no direct reporting of fatal drug reactions in nursing home residents. Nevertheless, researchers report:
“Finally, deaths attributed to negative therapeutic outcomes were estimated to occur in 2% to 4% of nursing facility residents.”
According to the Kaiser Family Foundation, in 2008 there were 1,388,383 nursing facility residents in the U.S. This gives a range of 27,768 to 55,535 deaths attributable to fatal drug reactions in nursing home residents each year. The mean is 41,652.
Kaiser Family Foundation State Health Facts.org (accessed 1/18/11).
Bootman, J.L., et al. “The Health Care Cost of Drug-Related Morbidity and Mortality in Nursing Facilities.” Arch. Intern. Med. 1997; 157:2089-2096.
Deaths Related to Misdiagnosis: 132,500.
Misdiagnosis is extraordinarily difficult to detect and measure, so the range of potential estimated deaths is wide. A landmark article in the Journal of the American Medical Association estimated 40,000 to 80,000 deaths in hospitals each year attributable to misdiagnosis. One of the authors, Peter Pronovost, MD, PhD, stated during an interview on our radio show that as many as 100,000 die from diagnostic errors and suggested that the number may be double that.
Researchers investigating discrepancies between diagnosis at time of death and diagnosis deducible from autopsy have determined that the major errors range from 4.1% to 49.8%. The median for errors that would have altered survival is 9.0%. The authors of this review conclude that 71,400 deaths in U.S. hospitals each year are related to misdiagnosis.
One of the country’s leading patient safety experts, Robert Wachter, MD, suggested in a personal communication that one way to estimate annual deaths from diagnostic errors in the country as a whole (hospitals, nursing homes and community) would be to multiply the total number of deaths per year (2.5 million) by the median diagnostic error rate of 9%. Although this estimate is extremely rough, that figure comes to 225,000.
With a range from 40,000 to 225,000, the mean is 132,500.
Newman-Toker, D.E. and Pronovost, P.J. “Diagnostic Errors–The Next Frontier for Patient Safety.” JAMA 2009; 301:1060-1062.
Shojania KG, et al. “Changes in Rates of Autopsy-Detected Diagnostic Errors Over Time: A Systematic Review.” JAMA. 2003;289:2849-2856.
Wachter, R.M. “Entering the Second Decade of the Patient Safety Movement: The Field Matures.” Arch. Intern. Med. 2009; 169:1894-1896.
Wachter, R.M., Personal Communication (email, Jan 11, 2011)
Health Care Acquired Infections in Hospitals: at least 100,000
The Agency for Healthcare Research and Quality (AHRQ) is the government’s watchdog on patient safety. Its reports are considered the most authoritative on this topic. In 2010 it summarized the findings from 2009 in its National Healthcare Quality Report:
“Infections acquired during hospital care (nosocomial infections) are one of the most serious patient safety concerns. They are the most common complication of hospital care. An estimated 1.7 million HAIs [healthcare-associated infections] occur each year in hospitals, leading to about 100,000 deaths. The most common infections are urinary tract, surgical site, and bloodstream infections.”
Other reports support this estimate including the Centers For Disease Control and Prevention.
Agency for Healthcare Research and Quality. “National Healthcare Quality Report 2009.” AHRQ Publication No. 10-0003: March 2010.
“Nosocomial Infections: Challenges in Vaccine Development.” The New York Academy of Sciences, online, Jan. 27, 2010, Presented by the Vaccine Science Discussion Group.
Richard, C. “Healthcare-Associated Infections: A Primer,” Presented at “Toward the Elimination of Healthcare-Associated Infections,” National Center for Preparedness, Detection, and Control of Infectious Diseases, Public Health Grand rounds, Office of the Director, Oct. 15, 2009, Centers For Disease Control and Prevention.
C. diff infections in Nursing homes: 16,500
This number comes from the Centers for Disease Control and Prevention (CDC). It is available on many PowerPoint presentations by CDC personnel. On October 15, 2009 the Office of the Director at CDC offered a Public Health Grand Rounds. It contained this: Nursing home-onset cases of Clostridium difficile cases: “263,000, $2.2 billion in excess costs and 16,500 deaths annually.”
Excessive radiation (CT scans): 29,500
This comes straight from the medical literature:
Berrington de Gonzalez, A., et al. “Projected Cancer Risks from Computed Tomographic Scans Performed in the United States in 2007.” Arch. Intern. Med. 2009; 169:2071-2077.
Unnecessary Surgery: 12,000
This too comes from the medical literature:
Starfield, B. “Is US Health Really the Best in the World?” JAMA 2000; 284:483-485.
Leape, L.L. “Unnecessary Surgery.” Health Serv. Res. 1989; 24:351-407.
Lethal Blood Clots in veins (deep vein thrombosis [DVT] and pulmonary embolism [PE]): 119,000
Estimated annual mortality ranges from 38,000 (following orthopedic surgery alone) to 177,000 to 200,000 (estimate from the Cleveland Clinic online resource): http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/cardiology/venous-thromboembolism/
Please note the quote from that site:
“Presently, there is no national surveillance of VTE, and current prevalence and incidence estimates are likely underestimates…Further, PE often presents as sudden death. Given that the number of autopsies performed in the U.S. is low, and that PE may be misdiagnosed as heart failure, current estimates of the number of PE events are probably low.”
Mean between high and low is 119,000.
The total number of VTE cases (fatal and nonfatal) in the U.S. ranges from 900,000 to 1,000,000. Roughly two thirds are hospital or healthcare-setting related. Blood clots in deep veins occur after surgery, immobilization and infection. According to numerous sources, VTE is the “leading cause of preventable hospital death and a leading cause of maternal mortality in the U.S.”
Beckman, M.G., et al. “Venous Thromboembolism: A Public Health Concern.” Am. J. Prev. Med. 2010; 38(4S):S495-S501.
Spyropoulos, A. C. and Lin, J. “Direct Medical Costs of Venous Thromboembolism and Subsequent Hospital Readmission Rates: An Administrative Claim Analysis from 30 Managed Care Organizations.” J. Managed Care Pharm. 2007; 13:475-486.
Heit, J. A., et al. “Estimated Annual Number of Incident and Recurrent, Non-Fatal and Fatal Venous Thromboembolism (VTE) Events in the U.S.” Blood 2005; 106:267A
Heit, J. A. “Venous Thromboembolism: Disease Burden, Outcomes and Risk Factors.” J. Thromb. Haemost. 2005; 3:1611-1617.
Heit, J. A., et al. “Relative Impact of Risk Factors for Deep Vein Thrombosis and Pulmonary Embolism: A Population-Based Study.” Arch. Intern. Med. 2002; 162:1245-1248.
Surgical and Postoperative Complications: 32,591
Zhan, C., and Miller, M. R. “Excess Length of Stay, Charges, and Mortality Attributable to Medical Injuries During Hospitalization.” JAMA 2003; 290:868-874.
Weingart, S. N., and Iezzoni, L. I. “Looking for Medical Injuries Where the Light Is Bright.” JAMA 2003; 290:1917-1919.
Total number of deaths from health care harm =788,558
Statistics are people with the tears wiped away. –Irving Selikoff, MD
Imagine the headlines today if a jumbo jet crashed and killed everyone on board. Now imagine three jumbo jets crashing on the same day. There would be cries of outrage, demands for explanations, investigations, and immediate corrections to air traffic safety.
The death toll from health care screwups adds up to at least 500,000 Americans annually. That is the equivalent of more than three jumbo jets crashing every day of the year (or over 1,000 jets annually). Because these individuals are dying at home, in hospitals, or in nursing homes, no one is counting the bodies. There is no outrage, no plan to change a system that allows too many to die unnecessarily. The medical profession seems largely immune to the consequences of its errors.
Think of it another way. We were told recently that 714,000 have died in the US from COVID-19. We do not mean to diminish the horrific tragedy that represents. But if our calculations are correct, we lose more than that every year from health care harm.
Why Our Public Health System Resists Change:
The CDC (also known as the Centers for Disease Control and Prevention) is the organization responsible for tracking causes of death in the United States. It lists deaths from heart disease at 614,348 and deaths from cancer at 591,699. Next comes “chronic lower respiratory diseases” at 147,101. No where in the CDCs leading causes of death can we find medical mistakes. It is invisible!
Because no one tracks the numbers of medical mistakes leading to death this epidemic goes unnoticed. We spend billions on research to treat cancer, heart disease, infections and diabetes but almost nothing on an effort to reduce our number one killer, medical mistakes.
What Can You Do To Protect Yourself or Someone You Love from Medical Mistakes?
Whether medical errors are the leading cause of death, as we have just asserted, or the third leading cause of death, as the Johns Hopkins researchers contend, you need strategies to keep from becoming a victim. We wrote Top Screwups Doctors Make and How to Avoid Them because we lost someone very dear to us due to a series of medical errors. We did not want anyone else to go through that agony. Here is our Safe Patient Checklist:
- Take a prioritized list of your top health concerns/symptoms.
- Ask the doctor for a recap to make sure you have been heard.
- Take notes or record the conversation: you won’t remember everything you have heard.
- Take a friend or family member to be your advocate and record-keeper.
- Get a list of all your medications and supplements so that interactions can be prevented.
- Find out about the most common and serious side effects your medications may cause.
- Ask the doctor how confident he or she is about your diagnosis. Find out what else could cause your symptoms.
- When in doubt, seek a second opinion.
- Always ask your providers to wash their hands before they examine you.
- Get your medical records and test results.
- Keep track of your progress: maintain a diary of relevant measurements such as weight, blood pressure or blood sugar readings.
- Be especially vigilant when moving from one health care setting to another. Mistakes and oversights are especially common during transitions.
- Ask how to get in touch with your providers. Get phone numbers or email addresses and learn when to report problems.
- Inquire about resources to learn more about your diagnosis or treatment.
In Top Screwups we have tips and question lists:
- “Top 10 Tips to Stopping Screwups in Hospitals (page 22)”
- “Top 10 Diagnostic Screwups (page 44)”
- “Top 10 Reasons Why Doctors Screw up Diagnoses (page 46)”
- “Top 10 Questions to Ask to Reduce Diagnostic Disasters (page 69)”
- “Top 10 Screwups Doctors Make When Prescribing (page 78)”
- “Top 10 Questions to Ask Your Doctor When You Get a Prescription (page 95)”
- “Top 11 Tips for Preventing Dangerous Drug Interactions (page 108)”
- “Top 10 Screwups Pharmacists Make (page 111)”
- “Top 10 Tips for Taking Generic Drugs (page 139)”
- “Top 10 Tips to Surviving Old Age (page 167)”
- “Questions to Ask Your Doctor Before Agreeing to Surgery (page 177)”
- “Top 10 Tips to Promote Good Communication (page 188)”
The study on medical mistakes from Johns Hopkins reminds us that the health care system is not likely to change any time soon. As a result, patients and their family must be proactive when it comes to preventing health care harm. We hope this book will provide you the resources you need to avoid becoming a statistic that likely would not be reported.
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