Posts Tagged medical error
According to a recent report in the BMJ medical errors are the third leading cause of death in the United States. The chart below shows where the estimated number of deaths from medical error fit into known mortality data. The article makes the remarkable observation “medical error” is not allowed as the cause of death to be recorded on death certificates. Indeed, when “medical error” is entered into the ICD 10 look up site for CMS here is the result: There are no ICD-10 Codes that match that fragment.
To be fair, the rule for death certificates is the cause of death must be the final cause. For instance, even though smoking causes heart disease which leads to a myocardial infarction (heart attack), the allowed cause of death is myocardial infarction rather than smoking, which is truly the root cause. That’s just how the system has worked for decades. So if a medical error causes a myocardial infarction the doctor must list myocardial infarction as the cause of death — in most states the qualifier “due to …” is allowed and smoking could be entered by the doctor. Interestingly, if “medical error” is listed the death would become an “accidental death” requiring review by the medical examiner (not something most physicians or families want).
251,000 deaths in the United States are caused by medical errors. This fact has been hidden, like many other underlying causes of death. The effect is that research into medical errors is lacking, the funding for research is lacking and the problem is ignored. Why should heart disease research be funded when some “cardiac” deaths are actually due to a nurse giving the wrong medication to the patient. The research really needed is to find how to prevent the medication error.
Although the graph above is bad enough, consider that the size of the bars for heart disease, cancer and COPD should all be smaller — because the real cause, in many cases, is medical error.
The number of medical errors is staggering. The errors that cause death are just the tip of the iceberg. Lots and lots of medical errors only have minor consequences. Every physician makes several errors each day. Every review of a medical chart reveals numerous errors. Care providers are astounded by this news. However, simple things like not seeing a lab report with a low blood count until the following day is an error even if nothing bad happened as a result. Of course, it would be malpractice if something bad did happen as a result.
The prevailing notion in quality improvement circles is, “don’t waste your time unless there was a bad outcome.” This notion comes from a lack of staff, and intense criticism when a provider is involved. “What do you mean there was an error, my care was excellent, nothing bad happened, you should be fired.”
Although there is a real tendency to want to blame an individual provider, both small and large errors are the result of poor clinical processes. Even errors due to provider fatigue and lack of sleep are truly process problems — a provider who worked during the night should not be working the following day. A provider sick with a cold should not be working, but so often they are.
What needs to be done:
- Just like alcoholism, the first step is to admit there is a problem.
- See medical care as a process. Strive to make sure the same problem gets the same treatment every time in every location. OR change the process.
- Stop seeing medical care as art. What work of art ever killed a person?
- Separate the compensation for medical errors from improving medical processes. Injured patients need quick compensation and medical care needs quick changes to improve. Lawsuits seem to have little impact on process of care — if lawsuits prevent errors why are we in this mess?
- Establish a non-profit foundation to advocate for reducing medical errors — something the public might be very willing to support. Sorry, Heart Association, Lung Association, Cancer Association — some money needs to go toward reducing errors. After all, if a wonderful heart medication is given to the wrong patient what good is that?
Hospitals are responsible to rescue patients from inappropriate treatment — especially when the need to intervene is obvious. The hospital has a board of directors responsible for the care delivered in a hospital. They hire the CEO who hires a quality manager. When bad quality management hurts or kills patients it is the hospital’s fault.
An article by Dr. Behnood Bikdeli and colleagues (JCHF. 2015;3(2):127-133) describes a huge study at 346 hospitals about treatment of patients with congestive heart failure (CHF). Here is the essence:
- CHF is life-threatening condition where the body collects too much fluid, usually due to a weak heart. The fluid gets into the lungs and causes shortness of breath.
- The treatment for CHF is to remove fluid from the body and give medications to improve heart and kidney function.
- The absolutely wrong thing to do is to give extra fluid by the veins.
- The study found about 12% of patients with CHF were treated with 1 to 2 liters of fluid in the veins during the first 2 days of hospitalization. AND, most alarming, compared to similar patients not treated this way, they were more likely to end up in intensive care or die.
- The most telling statistic is how often various hospitals let this dangerous use of intravenous fluid happen: 0% to 71%. This means some hospitals did not let it happen (0%). Some hospitals let it happen a lot (71%) — just hope your grandmother did not go to that hospital!
It is not rocket science to say fluid overload is not treated with extra fluid. This is easy to detect when the admitting diagnosis is CHF and the doctor orders say “NS IV at TKO” (translation: give salt water in the veins at a rate to make sure the veins stay open). NO NO NO the patient does not need extra fluid. This should not happen and there are lots of ways to prevent it or even rescue patients when Dr Welby writes such an order (or tries to use leaches).
- Mandate doctors use standard orders for treatment of CHF — there is plenty of latitude to customize such orders. But, IV fluid is not one of the choices without stating why.
- Educate staff that IV fluid is not required to admit a patient (an old fashioned insurance rule).
- Educate staff that IV fluid is not a cure-all. Fluid would help a dehydrated patient but not others.
- Nurses do a double check before admitting a patient from the ER with the question: does this patient have CHF and an order for IV fluids — if so, call the physician to clarify the situation or to change the order — no clarity=no admit.
- All CHF patients should be weighed daily — if the weight is going up it means more fluid is being retained — the patient needs to be rescued. Fix the problem or find someone who can, NOW.
Attention patient and family. This is easy to spot. The admitting doctor says the diagnosis is congestive heart failure but you see IV fluids being pumped into yourself or your family member. SPEAK UP! “Why is fluid treatment needed?” do not accept the answer of “everybody gets an IV”.
Attention hospital board members: do you know what your hospital is doing to prevent this obvious problem? Quality is your responsibility, you must do something besides listen to financial statements. Is your hospital the one with 0% or 71% record of treating CHF with IV fluids?