Monday, August 24, 2009

Dead By Mistake

Preventable medical errors and hospital acquired infections are still the largest causes of accidental death in US. The number of preventable deaths is approaching 200,000. There has been little change in the number of deaths from preventable medical errors since the seminal report on preventable medical errors, "To Err is Human".

Dead by Mistake, by a group of Hearst journalists, reports that "ten years ago, a highly publicized federal report called the death toll shocking and challenged the medical community to cut it in half — within five years. Instead, federal analysts believe the rate of medical error is actually increasing. In its 2008 annual report to Congress, the Agency for Healthcare Research and Quality, a part of the Department of Health and Human Services, reported that preventable medical injuries are growing each year by 1 percent, the first time it had reported such an increase."

As a result of this and other evidence, the Hearst journalists found that, since the original Institute of Medicine (IOM) study, there was no reason to believe that the 98,000 deaths per year attributable to preventable medical errors had declined. And the Center for Disease Control and Prevention found that 99,000 deaths were due to mainly preventable hospital infections.

The report "found that the the medical community, the federal government and most states have overwhelmingly failed to take the effective steps outlined in the report a decade ago." For example, the IOM report

  • Recommended national reporting of medical errors. Strong resistance from the AMA and the AHA effectively shelved this recommendation. Of the 20 states that have mandated reporting, "evidence shows that even in those mandatory-reporting states, hospitals report only a tiny percentage of their mistakes."
  • "Recommended the creation of a national patient safety center. The center is underfunded and has fallen far short of expectations.
  • Urged that hospitals improve the level of safety within their walls. Hundreds of hospitals responded, a few of them comprehensively pursuing safer care. Thousands did much less.
  • Advocated a voluntary system for hospitals to report and learn from errors. Five years later, Congress approved legislation for 'patient safety organizations' to serve this role, then took four more years to create rules to govern them. But the new organizations are devoid of meaningful oversight and further exclude the public."

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