Five years after a landmark study, patient safety remains in jeopardy


November 16, 2004


When Dr. Robert Wachter's wife underwent surgery in October to donate a kidney to a friend, her chief anxiety, he said, was "the possibility that she might be killed by a medical mistake."

She did fine, but Wachter, the chief of the medical service at the University of California, San Francisco Medical Center, says, "I didn't think she was paranoid at all."

Her concerns, like those of other patients, are a measure, he said, of the work the medical profession still faces five years after a landmark report warned that as many as 98,000 Americans die each year from preventable medical errors.

'Little bit of progress'

Wachter, a strong advocate for patient safety, spoke earlier this month at an anniversary forum assessing the medical community's progress since the report was released in November 1999 by a panel of the nonprofit Institute of Medicine. "We've made a little bit of progress," Wachter said, "but it has not been striking."

Dr. Lucian Leape, a member of the panel that wrote the report and an adjunct professor of health policy at Harvard University, agreed. "The evidence of improvement is, indeed, unimpressive," said Leape, who has written more than 100 papers on patient safety and quality of care.

Wachter and co-author Kaveh Shojania wrote a book, "Internal Bleeding," that discusses some of the more appalling examples of medical mistakes: The wrong limb is amputated; a patient receives another's heart surgery because of a name mix-up; a neurosurgeon operates on the wrong side of two different patients' brains; an intensive-care patient dies when an intravenous line is mistakenly flushed with insulin instead of blood thinner.

Such cases often were talked about in the hospital corridors and occasionally made the newspapers. But the institute report five years ago, with its stark mortality estimate, caused an uproar, provoking attention from politicians and patient advocacy groups.

While some experts questioned the number of estimated deaths annually - from 44,000 to 98,000 - Wachter said the report struck an immediate chord. The mortality rate, described in what he calls "jumbo jet units," was the equivalent of a jumbo jet crashing every day or two.

"Even if it wasn't a jumbo jet crashing every day but was simply a bus going over a guard rail every day," Wachter said, "I think you would say that's a big, important problem ... The report did a huge public service."

Fundamental problems

The report said medical errors are less a matter of recklessness by doctors and nurses than a result of fundamental problems with the way hospitals, clinics and pharmacies operate.

It urged new attention to basic safety practices and training as well as establishment of a mandatory reporting system for medical goofs that would build upon a patchwork of state systems.

It also recommended the creation of a national Center for Patient Safety to evaluate ways to identify and prevent medical errors and called for periodic re-examination and re-licensing of doctors, nurses and other key health providers.

Even before the 1999 report, New York had in place a mandatory system for reporting medical errors, as did many other states. Such systems can give officials clues to patterns of poor care or other problems.

Lack of funds, leadership

But the overall response to the institute report has been inadequate, Leape and others said, because of insufficient funding and a lack of national leadership. Despite attention in Congress, there is not yet a mandatory national system for reporting errors. Lawmakers have debated whether the reporting system should be mandatory or voluntary and whether the information gathered should be shielded from use in malpractice suits.

Nor is there a national Center for Patient Safety as recommended in the report. The federal Agency for Healthcare Research and Quality, founded in 1989, was asked by Congress in 1999 to do more to address some of the concerns raised in the report on medical errors. But Wachter said the agency effort remains underfunded. The White House sought $84 million in the 2005 fiscal year for the agency's efforts to improve patient safety, compared to $79.5 million approved by Congress for 2004.

Wachter said there have been encouraging signs, notably the effort by the private Joint Committee for Accreditation of Hospital Organizations to require strict attention to common-sense safety practices: use of checklists and a timeout (a pause to ensure that all preparatory steps have been taken before starting a surgical procedure); use of indelible ink to mark the limb or body part scheduled for surgery; readbacks of orders for prescription drugs.

Safety 'culture' lagging

Assessing the impact of the institute report remains difficult because of a lack of follow-up data, experts said. In cases where tougher reporting systems have been put in place, the information may be just sitting on a shelf or has not yet been analyzed for changes in the safety culture in hospitals and clinics.

Wachter took a poll recently of about 400 hospital-based physicians who were attending a medical conference. Forty-five percent said their institution had a better safety culture than when the institute report was issued in 1999. The rest said things had remained the same or gotten worse.

Medicine continues to lag behind other complex enterprises, such as the commercial airline business, in its attention to uniform reporting of problems and standardization of procedures, Wachter said.

It is not unusual, he said, for physicians and surgeons within the same hospital to use slightly different approaches to organizing staff and equipment in an operating room or intensive care unit.

"I can't imagine having a 767 cockpit set up different ways for different pilots," he said.

Wachter also cited a 2000 study in which both pilots and surgeons were asked if they considered it appropriate for subordinates to challenge their decisions if they feel mistakes are being made.

"Virtually every pilot says, 'Of course, are you crazy? You think I'm about to fly into a mountain, stop me,'" Wachter said. "And half of the surgeons say, 'No.'"

More technology help

While changing the culture of the operating room may be a challenge, there are other steps that can be taken, including the use of computers for medication orders rather than a doctor's sometimes illegible handwriting on the traditional prescription pad. Hospitals also have started to adopt electronic medical records to make it easier to track a patient's medical history from site to site and doctor to doctor.

"It is critically important to move ahead with the electronic health record," Leape said. Large medical centers and practice groups are more able to afford the cost of computerization, however, and specialists worry that smaller offices, often in rural areas, will lag behind.

Arthur Levin, director of the Center for Medical Consumers, an advocacy group in Manhattan, said those concerned about medical errors have not been able to build a political movement to press for more funding, despite the impetus of the 1999 institute report. He said the public and lawmakers must be convinced "that this is a real issue."

When things go wrong

  • Medical care complications in 2001 and 2002.

  • Birth trauma per 1,000 live births 7.358

  • Deaths per 1,000 discharges with complications potentially due to care 136.6

  • Foreign object accidentally left in body during procedure per 1,000 discharges 1.143

  • Selected infections due to medical care per 100,000 population 39.826

  • Central-line-associated bloodstream infection in ICU patients in 2002 5%

  • Complications of anesthesia per 1,000 surgical discharges 0.802

  • Accidental puncture or laceration during procedures per 100,000 population 36.8

  • Postoperative sepsis (infection in blood) per 1,000 elective surgery discharges 10.079

  • Obstetrical trauma per 1,000 instrument-assisted vaginal deliveries 239.454

  • Obstetrical trauma per 1,000 vaginal deliveries without instrument assistance 82.593

  • Obstetrical trauma per 1,000 caesarean deliveries 5.715

  • Adverse events associated with hip-joint replacement due to degenerative conditions 9.5%

  • Adverse events associated with hip-joint replacement due to fracture 22.6%

  • Adverse events associated with knee replacement 9.4%


Copyright (c) 2004, Newsday, Inc.


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