Three Years After a Landmark Report
Found Pervasive Medical Mistakes in American Hospitals, Little has Been
Done to Reduce Death and Injury from Medical Errors
When the august Institute of Medicine (IOM) issued its
blunt assessment of medical errors
three years ago, Lucian L. Leape, the pioneering Harvard physician researcher
who helped write the report figured it would meet a fate common to such
documents: The initial flurry of media accounts would be followed by
a swift descent into obscurity.
Instead, the report's conclusion that as many as 98,000 hospitalized
Americans die every year and 1 million more are injured as a result
of preventable medical errors that cost the nation an estimated $29
billion commanded attention in a way Leape and his co-authors never
Beginning in January hospitals will be required by accreditors to show
they meet six basic standards that reduce errors, which the IOM said
kill more Americans than breast cancer, traffic accidents or AIDS.
"Frankly we were all very surprised," recalled Leape, a former
pediatric surgeon and the author of several earlier groundbreaking studies
of medical errors. "Before the IOM report, nobody was doing diddly
squat. Now there are a lot of good people involved and a tremendous
amount of activity," he said. "Of course, activity is not
the same as progress."
The distinction drawn by Leape underscores the reality of the nascent
movement to reduce medical mistakes: There's a lot of talk, but no significant
progress. The reasons, observers say, include fierce resistance by doctors
and hospitals to mandatory reporting and other IOM recommendations,
a lack of oversight by the federal government and the absence of an
effective consumer lobby.
As a result, experts contend, it's doubtful that patients checking into
most of America's 5,200 hospitals today are any less likely to be killed
or injured than they were on November 29, 1999, when the report was
issued. With the conspicuous exception of the Department of Veterans
Affairs (VA) medical system, whose hospitals have embraced the ethic
and many of the methods that have made aviation and other industries
safer, most hospitals have taken few new steps to protect patients from
"I'd say patients are safer today in some hospitals, and certainly
in the VA, but it's still a pretty small minority," said physician
Don Berwick, a member of the IOM panel who is president of the Boston-based
Institute for Healthcare Improvement, a nonprofit group dedicated to
bettering the quality of health care. "Safety is a very hard thing
to accomplish and it has to be pushed way up to the top of the list,
and that still hasn't happened" in most places.
The vast majority of hospitals still rely on paper charts that often
can't be located and are difficult to decipher, rather than more accessible
and legible computerized medical records. Fewer than 3 percent have
fully implemented computerized drug ordering systems, which have consistently
shown dramatic reductions in drug errors. Operations performed on the
wrong body part or the wrong patient have increased, according to the
Joint Commission on the Accreditation of Healthcare Organizations (JCAHO),
which inspects hospitals.
The nation's most exhausted and inexperienced doctors -- the 100,000
interns and residents who staff teaching hospitals -- continue to work
as many as 130 hours a week, often with little or no supervision. Hospital-acquired
infections, which kill about 90,000 patients annually, have increased
36 percent since 1980, a rise that coincides with the proliferation
of bacteria capable of resisting the most potent antibiotics, according
to the Centers for Disease Control and Prevention (CDC).
Although the estimates of death and injury contained in the report
are huge, the actual number of deaths is undoubtedly higher. The
IOM considered only errors committed in hospitals, and not in other
medical settings where they undoubtedly also abound: clinics, outpatient
surgery centers and doctors' offices.
Experts say the nationwide shortage of registered nurses as well as
the unprecedented demands on emergency rooms have exacerbated an already
Well, in medicine, if someone makes a mistake, who gets hurt? It's not
the doctor. Who pays? It's not the hospital.
Medication errors are among the most common preventable mistakes, the
IOM report found, and they remain rampant in hospitals; experts have
estimated that more than one million serious drug errors occur annually
in hospitals alone. A recent report in the Archives of Internal
Medicine found that one in five doses of medication dispensed at 36
hospitals and nursing homes around the country was either the wrong
drug or the wrong dose, or given at the wrong time or to the wrong patient.
The more drugs a patient is taking and the more people involved in the
delivery of a medicine, the greater the chance of a mistake. The explosion
in the number of drugs on the market -- there are now more than 10,000
-- has increased the chances of error. So has the similarity of names
that can be easily confused, such as Lamisil, a drug prescribed for
fungal nail infections, and Lamictal, an epilepsy drug.
While many drug errors don't injure patients, others are lethal. The
most notorious of these, cited in the IOM report, is the massive
chemotherapy overdose that killed Boston Globe health reporter Betsy
Lehman, 39, in 1994 and gravely injured another woman. The circumstances
of Lehman's death, which was the subject of a front page story in the
Globe, rocked the Boston
medical establishment as well as cancer treatment centers
around the country. It is widely regarded as a watershed event that
led to the birth of the fledgling patient safety movement.
The Lehman overdose, which a dozen doctors, nurses and pharmacists failed
to notice, was caused by an initial miscalculation of a toxic breast
cancer drug, a mistake compounded by a cascade of other errors. They
include the failure of doctors at the prestigious Dana-Farber Cancer
Institute in Boston, a federally designated comprehensive cancer center,
to investigate complaints by Lehman's husband, a scientist at Dana-Farber,
or lab tests that indicated something was terribly wrong.
Other fatal medication errors
have resulted from the accidental overdose of concentrated drugs, particularly
potassium chloride. For decades these drugs were stored on hospital
wards where they were administered to critically ill patients as an
additive to intravenous solutions to restore electryolyte balance.
Sometimes harried or distracted nurses forgot to dilute them and mistakenly
administered a lethal injection. (Potassium chloride instantly stops
the heart and is used for this purpose in states that administer the
death penalty by lethal injection.)
Starting in January, the JCAHO will require that hospitals remove potassium
chloride and other hazardous concentrated drugs from patient floors.
While most have done so, "occasionally we still see holdouts on
specific nursing units," Cohen said.
Other common causes of drug errors include the use of abbreviations
such as "u" (short for units) which can be mistaken for a
zero, misplaced decimal points and doctors' legendarily illegible handwriting.
Three years ago a Texas jury awarded $450,000 to the family of a 42-year-old
man who sued a cardiologist and a pharmacist after he was given a massive
overdose of the wrong drug and died. The pharmacist said he had trouble
reading the doctor's writing.
To address the legibility problem, some hospitals have sent doctors
to remedial penmanship classes. Most experts consider this a poor substitute
for the more effective and expensive remedy endorsed by the IOM: computerized
drug ordering systems linked to a hospital pharmacy, which one study
found reduced medication errors by 86 percent. These systems also can
help prevent accidental overdoses, like the one that killed Lehman,
and make it virtually impossible for a doctor to prescribe a drug to
which the patient has a known allergy, another common mistake.
But so far, according to Suzanne Delbanco, executive director of the
Leapfrog Group, an organization of Fortune 500 companies that is pressuring
hospitals to improve quality and reduce errors, only 2.5 percent
of hospitals have fully implemented computerized drug ordering systems.
Nielsen agreed that physician resistance remains an obstacle. "Doctors
will give the nurse a verbal medication order and will write it down
and tell her" to enter it in the computer, thereby subverting the
system, he said.
Dennis S. O'Leary, the internist who directs the JCAHO, is adamant:
Surgeries in which doctors perform the wrong operation or operate on
the wrong side of the body or on the wrong patient "should never
Yet every year since 1995, O'Leary said, the commission has seen an
increase in voluntary, confidential reports of what is known as wrong-site
surgery. Since 1998, the JCAHO has issued two warnings to hospitals
about the problem.
The lack of a national error-reporting system means there is no way
to tell how often the problem occurs. Although cases reported to JCAHO
include the removal of the wrong breast or kidney or a biopsy on the
wrong side of the brain, the problem is believed to be most common in
In the case of Kevin Walsh, a 41-year-old construction worker from Staten
Island, N.Y., they were not. Last year, neurosurgeons at Long Island
College Hospital in Brooklyn operated on the wrong side of his brain
because a CT scan they were working from was reversed.
Canale said he was surprised at the opposition he encountered. "All
these famous prima donna orthopedic surgeons said, 'I don't have time
to go talk to a patient before surgery' or 'I've never made a mistake,
why should I do this?' And I said, 'You're exactly the kind of guy who's
going to get into trouble.' "
"In an airplane, the pilot and co-pilot go through a checklist
every time before they take off," O'Leary noted. "We don't
do that in a hospital."
After years of mostly futile attempts to persuade doctors, nurses and
other health care workers to wash their hands between patients, the
CDC recently unveiled its new "hand hygiene campaign." This
is the agency's latest effort to reduce the estimated 2 million infections
and 90,000 deaths annually caused by infections that patients pick up
in hospitals. Half of these infections could be prevented by proper
hand washing, according to the CDC.
Studies have found that hand washing is the exception rather than the
rule and is inversely related to status: Doctors are less likely to
wash than nurses' aides.
"There is no evidence that hospitals are doing anything about this
problem," said Inlander of the People's Medical Society. "This
is one of the most common errors and one of the biggest problems confronting
patients. And there's no pressure on hospitals to institute vigorous
hand washing programs."
Fatigue and Supervision
Despite numerous studies from aviation, aerospace, the military and
other industries linking fatigue with mistakes, sometimes fatal ones,
most of the nation's 100,000 interns and residents continue to work
80 to 120 hours per week. At night and on weekends, when senior doctors
are largely absent, these neophyte physicians are expected to make life-and-death
decisions with minimal guidance. Defenders of the current system say
that no studies have linked fatigue or inadequate supervision to medical
errors; some have said that doctors are different than other professionals
and learn to transcend exhaustion, in defiance of the laws of human
That may change. The federal Agency for Healthcare Research and Quality
is funding eight studies examining the relationship of fatigue, stress
and sleep deprivation to mistakes made by doctors and nurses in hospitals.
Long work hours by doctors "especially residents . . . are incompatible
with a safe, high quality health care system," warned Stanford
anesthesiologists David M. Gaba and Steven K. Howard in a recent article
in the New England Journal of Medicine. If organized medicine doesn't
reduce these excessive hours, they warn, "change may be ultimately
forced on us."
It's hard to know what role long hours might have played in the death
of Mike Hurewitz last January at New York's Mount Sinai Hospital, but
inadequate supervision was a factor, according to state investigators.
The 57-year-old Albany resident died after choking on his own vomit,
three days after he donated part of his liver to his brother, a physician.
Hurewitz was being cared for by an intern who told officials she felt
"overwhelmed" after being left alone in charge of 34 patients.
Experts say that the rapid turnover of registered nurses and their increasingly
large caseloads contribute to errors; so far there are few studies that
prove this. Two reports published in the past six months in the New
England Journal and the Journal of the American Medical Association
concluded that patients in hospitals where nurses had heavier workloads
had a higher risk of dying.
"Anyone who thinks that the nursing shortage and medical errors
are not causally related is not in this planetary system," said
O'Leary, who notes that an analysis of 1,609 serious errors reported
to the JCAHO over the last five years involved nurse understaffing.
The problem was also cited in New York's investigation of Hurewitz's
According to the AHA, 126,000 nursing jobs are vacant at American hospitals,
sometimes as the result of poor working conditions, and 56 percent of
hospitals are using temporary nurses who are far less likely to be familiar
with a hospital, its staff and its machinery than permanent staff. These
factors are all potential sources of error: Studies in aviation show
that people trained to work in teams make fewer mistakes than those
with no such experience.
Reformer Don Berwick said he remains hopeful that the awareness raised
by the IOM report will translate into programs that demonstrably reducte
errors. "I don't know why the public isn't more pissed off about
this. Imagine what the reaction would be if we had a similar mortality
in aviation." - Source: The Washington Post;
December 3, 2002;
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