Experts Seek Answers Behind Error Death Data
Health Grades Inc. released its estimate of error-related deaths last week, nearly doubling a 1999 estimate from the Institute of Medicine. That study shocked many in the medical community and helped spur efforts to improve patient safety systemically.
According to Bob Wachter, a professor in the Department of Medicine at UC San Francisco and the author of a well-respected book on medical errors, "Internal Bleeding: The Truth Behind Americas Terrifying Epidemic of Medical Mistakes," the new study is "flawed in some truly fundamental ways."
The Health Grades report used parameters newly developed by the Agency of Healthcare Research and Quality, as reported by codes in hospital administrative records.
In an interview with eWEEK.com, Wachter said the patient safety indicators were "really designed to give hospitals a sense for where to improve rather than saying flat-out that [a death] was a medical error." He said such an assessment would require examining specific details of individual incidents, something that was not done for the 2004 study.
In addition, the Health Grades report found that two categories not considered in the IOM report accounted for the largest proportion of deaths: failure to rescue and post-operative sepsis, or systemic infection. But Wachter said deaths from such causes were not necessarily due to medical mistakes.
"The report portrayed deviations from perfection as being errors," he said, even though some deaths still occur even with flawless care. If the rates of sepsis are higher at one hospital than at another, that hospital may have a quality problem, and "errors may be happening, but that does not mean every single death was an error."
Samantha Collier, vice president of medical affairs at Health Grades, defended the study, saying that cases of sepsis were only considered as a quality indicator for surgeries deemed unlikely to lead to life-threatening infection, so such incidents were most likely due to a complication of medication. In addition, she asserted that using administrative data would likely underestimate, not overestimate, the problem because cases could be coded to avoid indicating problems.
Still, both experts acknowledged that there was no reliable way to truly know how many people die each year from medical errors, and Wachter acknowledged that the figure could well be as high as 200,000 a year.
Wachter and Collier also agreed that solutions should be considered in terms of health care delivery systems instead of individual health care providers.
"A nurse giving wrong medicine is a slip, and the cure for slips is rarely telling someone to be more careful; its to develop systems," Wachter said. This will require health care providers to admitas individuals and as a communitythat individuals will make mistakes and that systems can prevent errors.
Still, information technology will play a crucial role in these health care systems. For example, information technology could find weak spots, an issue addressed in this months issue of Health Data Management.
Wachter imagined how such an analysis might work. "If we have an unduly high rate of sepsis, we might find out were not using the antibiotics at the right time or at the right doses." Systems might be set up that prompt antibiotics to be delivered before surgery, or that consider the type of surgery and patient conditions such as diabetes.
Such systems might include safety check measures such as bar-coding drug orders, as well as IT that streamlines the entire process to keep professionals from chasing paper and allows them to spend more time with patients.
IT that provides relevant information to nurses and doctors at the point of care could make a significant difference, Wachter said, perhaps by helping doctors to pick the best antibiotic given a particular patients medical history. But "we can count on one hand" the number of hospitals that can make updated, relevant information available in that way, he said.
In addition, he said, "many of the current systems are still a little bit unwieldy."
Wachter described one infamous failed system: In an effort to curb use of the overprescribed antibiotic vancomycin, the order system forced doctors to click through a series of screens to make sure the drug was truly necessary.
The time to order the drug increased from thirty seconds to five minutes and, as a result of such inconveniences, the doctors stopped using the system. No matter what information systems are set up, they cannot be successful unless they accommodate how doctors work, he said.
Nor can IT compensate for inadequate personnel, Collier added. She described a mistake in which a doctor selected the wrong patient when ordering medicine, and a nurse caught the error. "Information systems by all means will help do the job better," she said, but "first youve got to get the right people."