Contra Costa Times, Knight Ridder Newspapers September 13, 1999 Font Page

For a Systemic Problem, No Easy Fix

Part 2 of a four-part series

By Andrea Gerlin

As most Americans would, more than 30,000 patients who were admitted to 51 of the hospitals in New York state in a single year expected that the finest health-care system in the world would provide them every chance of recovery.

For some, the reality was otherwise: 1,133 of the patients suffered injuries caused by medical errors - not their underlying medical conditions. Of those, 154 died from the injuries.

Put another way, one of every 200 of the patients admitted to a hospital ended up dead because of a hospital mistake.

Those were among the key findings of the "Harvard Medical Practice Study," published in 1991 in the New England Journal of Medicine. It remains the most comprehensive and rigorous examination of hospital errors ever, while data supporting the findings throughout the country continue to mount.

"The facts are, we commit thousands of errors every week nationally," said David Nash, associate dean and director of the Office of Health Policy and Clinical Outcomes at Thomas Jefferson University.

"People get killed every day in hospitals," said Bertrand Bell, a professor at Albert Einstein College of Medicine in New York. "This goes on in every hospital in the United States. The public doesn't see it at all."

In interviews, top doctors at the University of Pennsylvania, Thomas Jefferson University, Harvard Medical School, Stanford University School of Medicine, the University of California at Los Angeles, and Albert Einstein College of Medicine in New York, said that medical errors are a serious and common problem at hospitals across the country. One reason, they say, is that the culture of medicine is founded on unattainable standards of perfection, and those ideals are reinforced by public expectations.

"The country spends an awful lot of money making sure cars and airplanes are safe," said David Gaba, a physician and professor at Stanford University. "But this is an issue that's been somewhat hidden because when there's a problem, it's not 100, it's one or two."

Lucian Leape, a pediatric surgeon and adjunct professor of health policy at the Harvard School of Public Health, who led the 1991 study, said those seemingly small numbers add up to one million people being injured by errors in hospital treatment every year - and 120,000 people dying as a result of those injuries.

"Health care is a huge industry, and injury is its number one problem," Leape said. "There's an incredibly long way to go."

When the Harvard study was published, it received little public attention. But organized medicine went on the defensive. The American Hospital Association disputed the conclusions. The American Medical Association attacked the researchers' methods and findings.

But as the decade has progressed, and as the public has shown declining confidence in the health-care system, the associations have changed course, and now frequently cite the work of Leape and his colleagues. The American Hospital Association even made medical-error reduction one of its top two quality initiatives for 1999.

"Most hospitals have systems in place, particularly in terms of medication, to make sure errors do not occur," said Jack Lord, chief operating officer of the AHA and a forensic pathologist. "There are clearly initiatives under way. Is there better coordination that could be done? Yes."

Nancy W. Dickey, a family physician who completed her term as president of the AMA in June, said: "We still believe that health care is extremely safe in this country when you consider the millions of interactions every year. However, it could be better. It could have better controls to prevent mistakes."

Medication mistakes represent a leading category of hospital errors, accounting for 19.4 percent of the adverse events in the Harvard study. Among the drugs most frequently at the center of medication errors are insulin, blood thinners and chemotherapy drugs. They are commonly prescribed in chronic conditions that can lead to hospitalization, and have lethal potential.

The largest number of errors - 48 percent - resulted from surgical treatment. By its very nature, surgery carries risks, some unforeseen and others preventable. Technical mistakes during surgery and wound infections afterward each accounted for roughly 13 percent of the adverse events identified in the study.

The Inquirer reported yesterday that internal records from the Medical College of Pennsylvania Hospital documented 598 incidents in which mistakes were suspected from January 1989 through June 1998. The confidential information became public as the result of a bankruptcy proceeding involving MCP's former owner. The hospital's experience reflects the events at hospitals across the country, according to national studies.

The Harvard study found that, on average, there was a 3.7 percent medical error rate at the hospitals in its sample. Other studies have found that only 5 percent to 10 percent of all medical errors are reported to hospital administrators; the remaining 90 percent to 95 percent go unreported.

At MCP, 140,000 patients were admitted during the period covered in the records. Based on an average error rate of 3.7 percent, 5,180 patients would be predicted to have experienced errors. The MCP records document 598 incidents. That represents about 12 percent of the predicted number of errors, which is consistent with the expectation that 5 to 10 percent of all errors are reported.

In addition, studies in New York and California have found that hospitals are sued for 2 to 10 percent of their medical errors. On that basis, MCP would be predicted to have faced from 100 to 500 malpractice lawsuits during the decade. The actual number of lawsuits was 266.

One study, published in part in 1997 in the journal Law and Contemporary Problems, found an overall error rate of 3 percent among 15,000 patients admitted to hospitals in Utah and Colorado. Another study, published in 1995 in the Journal of the American Medical Association, found that medication errors occurred in the care of 7 percent of patients at Massachusetts General Hospital and Brigham and Women's Hospital, major teaching hospitals in Boston.

The Harvard study examined the records of 30,121 randomly selected patients hospitalized in New York in 1984. Among the adverse events it found, 27.6 percent were judged as having been due to negligence, and 13.6 percent led to death. Adverse events were defined as injuries caused by medical management, not the underlying condition, that lengthened hospitalization or resulted in a disability upon discharge.

Doctors interviewed at leading medical centers agreed that hospital error rates could be reduced significantly. The steps would not be easy, they say. The change would have to be broad-based, requiring the medical profession to overhaul its culture and encourage openness about its limits. In addition, hospitals and the medical profession would have to use new technology and systems that have made improvement possible in other industries. And hospitals and doctors would have to develop more effective means of policing medical errors.

Harvard's Leape recalls that the late W. Edwards Deming, a pioneer in developing systems to improve industrial quality, told him that even a 99.9 percent proficiency rate was unacceptable in most industries. It would result in two unsafe airplane landings a day at Chicago's O'Hare airport; 16,000 pieces of lost mail every hour; and 32,000 checks deducted from the wrong bank account every hour. Assuming that rate could be achieved in health care, it would still leave thousands of patients dead each year as the result of medical error.

Paul H. O'Neill, chairman of aluminum producer Alcoa and chairman of RAND Corp., a California think tank, spent 10 years in the White House developing health-care policy during the Johnson, Nixon and Ford administrations. O'Neill said in an interview that the error rate in hospitals could be reduced substantially.

"If we decided as a nation that we were going to have a 90 percent or 95 percent improvement in outcomes as far as patient errors were concerned, we could," O'Neill said.

Bell, the Einstein professor, practices medicine at Jacobi Medical Center. He said he is so aware of the potential for medical error at hospitals that he once left a stern warning for residents in the medical record of a patient whom he had admitted.

"I put in the chart: 'DO NOT KILL MR. CROOKS.' " Bell said the warning was not sufficient. Though medical residents did not kill the patient, they mistakenly gave him insulin, which caused a seizure. "They put him into hypoglycemic shock," Bell said. "I'll admit somebody to the hospital, and they'll do all sorts of things. This is at my own hospital!"

Gaba, director of the Patient Safety Center of Inquiry at the Veterans Administration Health Services Center in Palo Alto, Calif., and an associate professor of anesthesiology at Stanford University School of Medicine, said his institution is no different from others. "The problems we have, in terms of suboptimal care, are the same as everywhere else," Gaba said.

Michael Cohen spent 14 years as a pharmacist at Temple University Hospital and Quakertown Hospital. Today he is the full-time president of the Institute for Safe Medication Practices, a small nonprofit organization based in Huntingdon Valley. His group collects 50 to 60 confidential reports of drug errors each month and sends weekly alerts to 5,800 hospital pharmacies around the country.

Cohen got started in the field after a dire episode while he was at Temple in 1975. "A patient was killed by an insulin order," he said. In that case, Cohen said, the doctor wrote a prescription for 6 units of insulin, abbreviating "units" to the letter "u." The letter was read as a zero in the pharmacy, and the patient received 60 units of insulin, or 10 times the proper dose.

The reasons that mistakes occur are multiple and complex. Errors were a problem long before managed-care pressures led to cutbacks at hospitals in the last decade.

Many doctors point out that given the number of opportunities they have to err, it is remarkable that more mistakes do not occur. A study presented at a 1989 conference in Denver found that 178 "activities" were performed each day on the average patient in an intensive-care unit, with 1.7 errors occurring, or a 1 percent daily rate.

Many mistakes have what in retrospect seem to be simple origins in poorly designed systems, experts say. Patient care becomes fragmented as doctors and nurses change shifts or more consultants join the treatment team, multiplying the risk of communication breakdowns.

Different medications may come in similar packages or have similar names.

Handwritten prescriptions and medical charts are frequently illegible.

"People die of penmanship errors," said Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania Health System. "Anybody who thinks that a system that keeps paper records in script is ready to deal with error is dreaming. You've got a 19th-century Charles Dickens system in an era of high technology."

Almost uniformly, doctors and researchers cite an unrealistic and less than honest culture among medical professionals as the single most important factor that contributes to errors.

Beginning in medical school, the culture of medicine discourages acknowledging mistakes, asking for assistance, exhibiting any weakness, or challenging a supervisor. In medicine's carefully ordered hierarchy, admitting or pointing out a mistake is frowned upon.

Doctors have traditionally dealt with errors at teaching hospitals' weekly "morbidity and mortality" conferences. They gather in confidential settings - with legal protection provided by state laws - to discuss among themselves what went wrong in the care of patients who died or suffered complications.

The pressure under which doctors and nurses work, deprived of sleep and motivated by fear of making mistakes, can actually increase the chances that they will make errors. "It's well-known that people are more likely to make mistakes when they're tired, overworked, hungry, bored, anxious, frightened, in a hurry, and under pressure from above," Leape said.

In addition, there is little incentive for hospitals to acknowledge and deal with the problem of medical errors.

Hospital executives, for example, face business pressures to deny the occurrence of medical errors, lest they be sued and have to pay for them. As in most other fields, colleagues are usually reluctant to say anything negative about their peers - especially to outsiders - while subordinates such as residents or nurses fear retribution. Lawsuits that are settled after serious errors are almost always resolved quietly in exchange for confidentiality agreements to avoid adverse publicity.

"It's a cultural barrier we have to overcome to talk about our defects," said Nash, the health policy director at Thomas Jefferson University. "What do hospitals do with their risk-management reports? We bury them as fast as possible."