Experts Seek to Understand Epidemic of Medical Errors

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Sept. 11, 2000 (Washington) -- While it's clear that preventable medical mistakes happen every day in America, what to do about this tragedy remains largely a mystery. That's why experts gathered here Monday at a federally sponsored meeting. Their goal was, if not to find the answers, at least to figure out where to start looking.

"We're going to treat this like an epidemic. We're going to have to declare war on medical errors," said John Eisenberg, MD, operating chairman of the Quality Interagency Coordination Task Force, which sponsored the one-day meeting. It's described as a national summit to set a research agenda on medical errors and patient safety.

The conference was triggered by an Institute of Medicine report titled "To Err is Human: Building a Safer Health System." The IOM, an adjunct of the National Academy of Sciences, documented between 44,000 and 98,000 preventable deaths from medical errors in the U.S. annually. The financial loss is estimated at up to $29 billion a year.

The analysis was issued last November, and shock waves from it quickly reverberated to the White House, where President Clinton announced an unprecedented program to reduce the number of deaths from medical mistakes by half in five years.

This week, the study has been followed by a three-part series running in the Chicago Tribune. Based in part on an analysis of computerized records from the FDA and the Health and Human Services Department, the newspaper report says more than 1,700 hospital patients have been accidentally killed and more than 9,500 others injured since 1995 "from the actions or inaction of registered nurses across the country, who have seen their daily routine radically altered by cuts in staff and other belt-tightening in U.S. hospitals."

Susan Sheridan of Boise, Idaho, has firsthand experience with medical mistakes. At the hearing, she described how her son Cal, now 5 years old and starting kindergarten, suffered brain damage just after he was born in 1995. "He is unable to crawl, and he's hearing and speech impaired, all because of a failure [to perform] a $27 test [that] could have prevented his condition," said Sheridan.

The family lost their first round of a malpractice case following the incident but have since been granted a new trial.

Coincidentally, Sheridan's husband, Pat, had a spinal tumor removed in 1999. At the time, the Sheridans were told the tumor was benign. But six months later, it reappeared as a much larger, more aggressive tumor and was diagnosed as malignant. The family was shocked when records showed that the first tumor was actually cancer.

"How do you restore ethics to a medical system? I think it's too easy for doctors and hospitals to cover up what is happening to patients," Sheridan told reporters.

A variety of experts agree on that point and want to open the reporting of medical errors to public inspection. State governments around the country are considering a mix of mandatory and voluntary error-reporting plans. The hope is that such reporting could help doctors learn from their errors without fear of reprisal, much in the way airline pilots do when they discuss close calls.

A former chairman of the American Hospital Association who attended the summit called for filling the gaps in patient-safety research. "As good as our systems are for preventing and reducing medical errors of all kinds, we can and must do better," said Gordon Sprenger, CEO of the Allina Health System in Minneapolis.

But the American Medical Association fears many doctors wouldn't come forward for fear of malpractice suits. "We don't think that mandatory reporting as it's been out there right now has worked very effectively," said the AMA's Timothy Flaherty, MD. Researching medical errors, Flaherty said, can only work if "it's confidential, non-punitive, and oriented to professional and organizational learning."

One of the most trouble-prone areas is dispensing drugs. Handwriting errors can be lethal. For instance, the term "u" for unit can be misread as a zero, thus increasing a dose of medication ten-fold. Computers could reduce that toll by half, but many hospitals still don't use such a system.

"Too often we've seen the same types of errors repeating themselves, and we know darn well that they're going to continue," said Michael Cohen, a pharmacist with the Institute for Safe Medication Practices.

Another patient-safety firewall could be an electronic medical record system, which in theory would be less error prone than paper. The Kaiser Permanente health maintenance organization is committing $1 billion to bring such a system to its 8 million patients throughout the country.

Researchers also plan to look at incentives to enhance safety, but it's not yet clear what form these might take. "Should we be punitive? Should we offer rewards? Is it regulations? Is it just disclosure of data? Again, it's untested ground," said Steve Wetzell, of the Leapfrog Group, a coalition that includes some of America's major corporations.

The IOM has recommended that $100 million be spent on medical errors research over the next three years. Currently, $50 million is pending in next year's federal budget for the U.S. Agency for Healthcare Research and Quality to study patient safety.

For more information from WebMD, join our live discussion on Medical Errors and Patient Safety at 5:30 PM EDT Tuesday, Sept. 12.


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