Report Cites Deadly Medical Errors

The Associated Press Nov 30 1999 2:18AM ET
reprinted for educational purposes only

Medical mistakes are a stunningly huge problem, says a new report by the Institute of Medicine. It quoted studies estimating that at least 44,000 and perhaps as many as 98,000 hospitalized Americans die every year from errors.

``To err is human'' is the report's title, but it stresses that ways exist to prevent many mistakes by anticipating health workers' weaknesses and designing safeguards.

The report recommends major changes to the nation's health care system to set as a minimum goal a 50 percent reduction in medical mistakes within five years.

``Errors can be prevented by designing systems that make it hard for people to do the wrong thing and easy for people to do the right thing,'' said William Richardson, president of the W. K. Kellogg Foundation, who co-authored the report.

There are constant places for doctors, nurses, pharmacists and other health workers to trip.

Doctors' notoriously poor handwriting too often leaves pharmacists squinting to decipher a dose - was it 10 milligrams or 10 micrograms? - or even the name of the prescribed drug.

Too many drug names sound confusingly alike. Consider the painkiller Celebrex and the anti-seizure drug Cerebyx; or Narcan, which treats morphine overdoses, and Norcuron, which can paralyze breathing muscles.

Medical knowledge grows so rapidly that it is difficult to stay abreast of the latest treatment or newly discovered danger. Technology poses hazards when device models change from year to year, leaving doctors fumbling for the right switch.

And most health professionals do not have their competence regularly retested after receiving their license to practice, the report said.

In fact, health care is a decade behind other high-risk industries in improving safety, the report said. It pointed to the transportation industry as a model: Just as engineers design cars so they cannot start in reverse, and airlines limit pilots' flying time to keep them rested, so can health care be improved.

Some fixes already are under way: Some hospitals have computerized prescriptions. The Food and Drug Administration is hunting ways to catch sound-a-like drugs. Anesthesiologists persuaded many manufacturers to standardize equipment and thus decreased technology-caused errors. Many doctors now literally mark the spot of surgical incisions before patients are put to sleep, so everyone agrees on what will be cut.

But the Institute of Medicine said reducing medical mistakes requires a bigger commitment. It recommended:

Congress should establish a federal Center for Patient Safety. It would require $35 million to start and should eventually spend $100 million a year in safety research. Still, that represents just a fraction of an estimated $8.8 billion spent yearly as a result of medical mistakes, the report calculated.

The government should require that hospitals, and eventually other health organizations, report all serious mistakes to state agencies so experts can detect patterns of problems and take action. About 20 states now require error reporting, but how much and what penalties they impose varies widely.

State licensing boards and medical accreditors should periodically re-examine health practitioners for competence, stressing safety practices. Standardized medical equipment and treatment guidelines can help doctors keep up.

Change the ``culture of secrecy'' that surrounds medical mistakes, encouraging doctors to discuss errors as well as near-misses so problems are fixed.

The Institute of Medicine is part of the National Academy of Sciences, a private organization chartered by Congress to advise the government on scientific matters. Congress just passed legislation ordering the Agency for Health Care Policy and Research to hunt strategies to reduce medical mistakes. The bill will even change the name to the Agency for Healthcare Research and Quality to reflect the emphasis. President Clinton is expected to sign the bill soon.

``Any error that causes harm to a patient is one error too many,'' said Dr. Nancy Dickey, past president of the American Medical Association, which already has started a National Patient Safety Foundation to address some of the problems.

But she cautioned that some changes will be difficult because doctors are liable for any mistake. ``We may know to talk about a culture of safety, but we still live in an environment of blame,'' she said.