When the Institute of Medicine published its landmark 1999 study “To Err Is Human,” finding that up to 98,000 patients die each year in hospitals due to medical errors, the medical industry had a swift response. Within a year, both the Journal of the American Medical Association (JAMA) and the New England Journal of Medicine published studies denying these findings. The articles were titled respectively, “Deaths due to medical errors is exaggerated in Institute of Medicine report" and “The Institute of Medicine report on medical errors-could it do harm?”
Guess they had to do something. The image of two 737s crashing every day for a year clearly wasn’t “on message” when it came to the AMA’s massive lobbying effort to enact laws to drastically limit compensation to harmed patients. And as these studies show, the push-back worked to some extent as a bunch of states responded to the epidemic of malpractice by capping damages to injured patients. Even as late as 2011, those anti-IOM studies were thrown in the face of patient advocates testifying against congressional legislation to drastically cap compensation to patients nationwide. (Check out this video, beginning at 3:56!)
So when news broke everywhere yesterday about the new article by Dr. Martin A. Makary of the Department of Surgery at Johns Hopkins University School of Medicine, I admit I had to brace myself. Dr. Makary found that the IOM figure was “limited and outdated” because the number was likely four times higher. Indeed, medical errors are the third leading cause of death in America. The push back may have already begun.
Medical errors are not officially listed by the Centers for Disease Control and Prevention as an official cause of death. Pro Publica, which first calculated the “third leading cause of death” figure in 2013, notes that Dr. Makary is “call[ing] for changes in death certificates to better tabulate fatal lapses in care. In an open letter, they urge the Centers for Disease Control and Prevention to immediately add medical errors to its annual list reporting the top causes of death."
Bob Anderson, chief of the mortality statistics branch for the CDC, disputed that the agency’s coding is the problem. He said complications from medical care are listed on death certificates, and that codes do capture them. The CDC’s published mortality statistics, however, count only the “underlying cause of death,” defined as the condition that led a person to seek treatment.
As a result, even if a doctor does list medical errors on a death certificate, they are not included in the published totals. Only the underlying condition, such as heart disease or cancer, is counted, even when it isn’t fatal.
Anderson said the CDC’s approach is consistent with international guidelines, allowing U.S. death statistics to be compared with those of other countries. As such, it would be difficult to change “unless we had a really compelling reason to do so,” Anderson said.
[And, he] said, it’s an “uncomfortable situation” for a doctor to report that a patient died from a medical error. Adding a check box to the death certificate won’t solve that problem, he said, and a better strategy is to educate doctors about the importance of reporting errors.
And therein lies the rub. Underreporting of errors is already a massive problem. (Check out the Center for Justice & Democracy’s Med Mal Briefing Book, p. 92 et seq., for lots of studies describing this phenomenon.) And if you think "fear of being sued" is the cause of underreporting, think again.
According to a January 2012 study, “Hospital employees recognize and report only one out of seven errors, accidents and other events that harm Medicare patients while they are hospitalized" because hospital employees do not seem to know what patient harm is and if they do, they think it is someone else’s job to report it.
Specifically, “[T]he problem is that hospital employees do not recognize ‘what constitutes patient harm’ or do not realize that particular events harmed patients and should be reported.… In some cases … employees assumed someone else would report the episode, or they thought it was so common that it did not need to be reported, or ‘suspected that the events were isolated incidents unlikely to recur.’”
Yet rather than trying to solve this problem, the medical community seems to be moving in the opposite direction – the direction of never reporting errors at all!
As Mark Twain may (or may not) have put it, “Denial ain't just a river in Egypt.”