Medical error is the third leading cause of death in the United States — but it’s not something that health care workers feel free to discussBy
If medical error was a disease it would rank as the third leading cause of death in the United States, concludes a study just published in the British Medical Journal.
The report pegs the number of deaths at 251 000 a year, a full 100 000 deaths ahead of respiratory illness, which is next in line. Moreover, as high as this number is, it probably underestimates the scope of the problem: “That’s using some of the most conservative numbers in the literature,” says lead author Martin Makary, MD, MPH, and professor of surgery at Johns Hopkins University School of Medicine in Baltimore.
Others agree. Jim Rickert, MD, who was not involved in the study, is an orthopedist in Bedford, Indiana, and president of the Society for Patient Centered Orthopedics. He told Medscape Medical News he was not surprised medical error came in at number 3 and that even those calculations don’t tell the whole story. For example, he notes that the 251 000 figure “doesn’t even include doctors’ offices and ambulatory care centers.” “That’s only inpatient hospitalization resulting in errors,” he says.
And then there’s this: Medical error causing patient death is apparently medicine’s dirty little secret. In an interview with the BMJ, Dr. Makary says: “These are issues that have lived in locker rooms and doctor’s offices and nursing stations where people talk about [these] stories. And it’s almost as if everyone knows of examples they’ve witnessed or know of. But they live in the form of stories and not in epidemiological numbers.”
Notice something else, too: the 251,000 figure refers to medical error causing death. Medical error also causes patient harm that falls short of death. For example: a needlessly prolonged illness, multiple hospital readmissions, the need for surgery, placement in the ICU, further physical and emotional suffering, and so on.
The following chart is taken from the study:
Makary defines medical error in the traditional sense, for instance: a misdiagnosis, a medication mistake, bad judgment, inadequate skill, poorly coordinated care, or a communication breakdown. But he notes that these traditional categories are expanding to include, for example, preventable factors and events, i.e. acts of omission, such as the failure to treat.
So in this emerging category of acts of omission causing harm, consider this fairly typical example of failure to treat in the context of infectious illness. Do you think it constitutes medical error today, and if not, should it?
Imagine, then, you’re in charge of a patient who you know to be colonized with the “superbug” methicillin-resistant staphylococcus aureus (MRSA). Your patient’s name is Sue, a 40-year old single mother of three, aged 7, 10, and 12. She’s been successfully treated for a pneumonia and is about to be discharged. She’s not infected by the MRSA but you’re aware of an important study reported in Clinical Infectious Diseases that says there’s a 1 in 4 chance that she could become infected. And you know that infection leads to the type of harm described two paragraphs above, i.e. multiple hospital readmissions, the need for surgery, etc., which, aside from her own suffering, would jeopardize her income and thus her ability to care for her children. Further, you’re aware of another study that says there’s even a 1 in 7 chance your patient will die if, in fact, she were to become infected with MRSA. So you’re faced with a question: Do you “decolonize” her? That is, do you get rid of the MRSA residing on her skin or in her nostrils, where it’s typically found, thereby removing the foreseeable risk of infection and consequent harm?
The obvious answer would be to decolonize. However, and surprisingly, that is actually not done in most jurisdictions. And here’s the thing: should Sue become MRSA-infected and get sick, or perhaps die, your decision not to treat would not (yet) be considered medical error — at least by health care providers — because non-treatment is the standard of care throughout the land: i.e. that’s how most providers handle a case like this. (But whether a court of law would see it as medical error — as medical negligence — is quite another matter: If your mechanic knew that your car had somewhat faulty brakes and failed to fix them, or failed to even tell you about them, and you crashed as a result, you would have an actionable claim against your mechanic.)
Makary says that “most people underestimate the risk of error when they seek medical care,” calling it a problem that is “vastly underappreciated and not even recognized.” Sue’s case may very well fall within the scope of these statements. If so, her plight is yet further proof of the “vastly underappreciated” nature of this problem.
Ultimately, though, how much harm we can attribute to medical error is unknown, and to some degree probably unknowable. Nevertheless, “the same mistakes happen again and again,” says Dr. Makary, in his interview with the BMJ; and, what’s more, “they’re never investigated.” Which leads us to what he considers the most surprising thing about medical error, what he calls the “Wall of Silence”: the fact that “We haven’t even begun to recognize the third leading cause of death in the United States.”
Makary is right, of course: We haven’t publicly recognized it. But inside those locker’s rooms, doctor’s offices, and nursing stations that he mentions above, are a host of dedicated people who, my guess would be, want to give voice to the issue, both within their ranks, and publicly. But they operate inside what’s been called an “environment of fear.” And so the question becomes: What will it take to change that culture to permit a much-needed open and honest exchange about an issue that in one way or another affects each one of us?
What do you think?