Yeah, that is actually a slight underestimate. Basically the average hospital patient receives 120 procedures per day, with a 1% error rate. Of those errors, an estimated 10 - 15% cause death or disability. The links I posted in my other comment to that IOM article and the Leape analysis of it basically support this, although I can't find an exact cite for that 120 procedures per day stat.
edit: It looks like I'm mixing measurements slightly. Basically I did find the source of that stat, it is here:
"There was an average of 178 activities per patient per day and an estimated number of 1.7 errors per patient per day. For the ICU as a whole, a severe or potentially detrimental error occurred on the average twice a day. Physicians and nurses were about equal contributors to the number of errors, although nurses had many more activities per day."
"Two large studies, one conducted in Colorado and Utah and the other in New York, found that adverse events occurred in 2.9 and 3.7 percent of hospitalizations, respectively. In Colorado and Utah hospitals, 6.6 percent of adverse events led to death, as compared with 13.6 percent in New York hospitals. In both of these studies, over half of these adverse events resulted from medical errors and could have been prevented.
When extrapolated to the over 33.6 million admissions to U.S. hospitals in 1997, the results of the study in Colorado and Utah imply that at least 44,000 Americans die each year as a result of medical errors. The results of the New York Study suggest the number may be as high as 98,000."
Also from the IOM report:
"In a study of 1,047 patients admitted to two intensive care units and one surgical unit at a large teaching hospital, 480 (45.8 percent) were identified as having had an adverse event, where adverse event was defined as “situations in which an inappropriate decision was made when, at the time, an appropriate alternative could have been chosen.” 41 For 185 patients (17.7 percent), the adverse event was serious, producing disability or death. The likelihood of experiencing an adverse event increased about six percent for each day of hospital stay."
Then Leape in his own analysis explains why even the 98,000 figure is probably a fairly large underestimate:
"The [IOM] study’s most serious limitation is probably that it was a retrospective medical record review study. Many important events in patient care are not recorded in the medical record. Some errors are not even known to clinicians caring for the patient. Studies of autopsy, for example, have found potentially fatal misdiagnoses in 20% to 40% of cases. On balance, the reliance on information extracted from medical records most likely led to a substantial underestimate of the prevalence of injury."
"They undoubtedly missed some that did occur because many adverse events and errors are never recorded in the medical record, either because they are concealed or not recognized. Other errors are discovered after the patient is discharged. In fact, in the MPS, an additional 6% of hospital-caused adverse events were discovered after discharge, but were excluded from the analyses because they were an unknown fraction of all such events. Therefore, any record-review study produces at best a 'lower bound.'"
"Second, neither of the large studies examined the extent of injuries that occur outside of the hospital. More than half of surgical procedures (numbering now in the tens of millions) take place outside of a hospital setting, and the adverse event rates for these procedures have not been studied. Even if complication and death rates are much lower than in-hospital care, the absolute numbers must be substantial, as suggested by the recent report of deaths associated with liposuction."
"Third, when prospective detailed studies are performed, error and injury rates are almost invariably much higher than indicated by the large record-review studies. In a large study of patients who died from acute myocardial infarction, pneumonia, or cerebrovascular accident (conditions that account for 36% of all hospital deaths), DuBois and Brook found that 14% to 27% of deaths were preventable. Andrews et al found that 17% of intensive care unit patients had preventable serious or fatal adverse events. The Centers for Disease Control and Prevention estimates that 500,000 surgical-site infections occur each year. One large controlled study found the excess mortality rate of surgical-site infections to be 4.3%, suggesting 20,000 deaths annually from this cause alone. These data are strong evidence that record-review studies seriously underestimate the extent of medical injury."
It pains me the HN approach to these kinds of problems: Hospitals aren't great, so therefore they're death camps. What's the recommendation then? Stay at home the next time something happens to your health? You'll fare better that way? "Read 3 books" about every procedure? Lots of my patients have poor medical literacy, are scared, and wouldn't care enough to read even if the first 2 factors were absent. I'd love it if everyone was an expert in his/her disease process, but that's like asking for zero highway accidents.
I look forward to the improvements we can make, including with systematic improvement of things we take for granted (the wonderful Pronovost study). But I feel like it's impossible to have a blogger-style discussion about these kinds of things without everyone being a know-it-all that doesn't actually provide anything in the way of solutions.
The OP problem is so beyond complicated that I'm not even sure how to approach the headline.
I mean this is obviously true for the larger population. Studies show that 90 million Americans can't even understand the directions on their prescriptions. But that recommendation was meant for the HN readers, most of whom can at least read and understand trade books.
"What's the recommendation then? Stay at home the next time something happens to your health?"
No, but I but I think the least you can do is to try to get in and out in a timely manner, rather than dawdling around for an extra day or two.
Also, if you actually learn to manage your health conditions you shouldn't need to be in the ER very often in the first place, unless you break your leg or something and you clearly need to go.
Also, hospitals are starting to be required to report some basic data now so consumers can make more educated decisions about where to go.
And lastly, you can look up the statistics about how good hospitals are at treating different things in general. For example, according to the Commonwealth Fund report from last year ("Why Not The Best?"), hospitals have gotten much better at treating heart attacks in the last five years. Granted, you'd still need to go to the ER if you were having a heart attack anyway, but at least you know now that you have a 96% chance of getting evidence based medicine going in.
"Hospitals aren't great, so therefore they're death camps."
Well I mean it's not like I'm making this up, it's what the IOM and the AMA are saying. As well as the Commonwealth Fund, the NEJM, and basically every other credible source.
Having read How Doctors Think and other similar books, I realize that much of medicine is very difficult, and there are good reasons for why things go wrong sometimes. But at the same time, doctors really shouldn't be cutting off the wrong limbs and giving people the wrong dosages of medicine on a daily basis.
Thanks for the comments; you bring up good points and I was probably being a bit expansive.
When I was a medical student, I used to ask patients, just prior to discharge, what their hospitalization was for, what their primary diagnosis was, what's the follow-up, etc. I was absolutely disheartened at how few people had any clue whatsoever (though some were due to poor communication on our part). But then again, as a patient it's a ton of work to really be on top of your care. I've tried tagging along with family members who were hospitalized and even I had to press to follow everything.
I've never been hospitalized, so maybe I'm not able to understand the emotional impact of being in those huge, strange buildings on the other side of the white coats (which I refuse to wear anymore for a lot of reasons). I've been on prescription pain pills once, and quit after 2 days because they made me so sleepy; I preferred the pain. So I'm constantly struggled to really get inside the mindset of any patients who don't articulate their thoughts.
Yikes, don't know where I'm going with this. I'd like things to change, but have no idea where to start.
I mean about half the problems you could get rid of just by cleaning up all the corruption in pharma and the FDA. The two books I've read that both have some pretty good stats and recommendations on this are:
The Truth About Drug Companies by Marcia Angell
Overdosed America by John Abramson
The problems are way too numerous to list, but they're extremely important.
The second thing that needs to change is that we need more data about the state of health care, as well as unbiased research into drugs. The commonwealth fund makes the case that we actually do a decent job of improving at the things we measure, but for the vast majority of the healthcare system we have no idea how safe or effective it is.
The third thing is that medicine needs to actually be regulated like any other industry. Doctors in this country are basically given a free pass for killing people, and that needs to change.
And lastly, as you say, our education system needs to be fixed. It doesn't work to have a society where only 3% of Americans can actually read at the level that college graduates are supposed to be able to read at.
Oh, and all of this needs to be done by the government, or by a combination of government and NGOs. Having private companies do healthcare is a disaster.
