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lightly. If Leape had instead calculated the average rate among million patients are injured in US hospitals each year, and approx- the three studies he cites (36%, 20% and 4%), he would have imately 280,000 die annually as a result of these injuries. come up with a 20% medical error rate. The number of fatalities Therefore, the iatrogenic death rate dwarfs the annual automobile that he could have presented, using an average rate of injury and accident mortality rate of 45,000 and accounts for more deaths his 14% fatality rate, is an annual 1,189,576 iatrogenic deaths, or than all other accidents combined."” over 10 jumbo jets crashing every day. At a press conference in 1997, Dr Leape released a nationwide Leape acknowledged that the literature on medical error is poll on patient iatrogenesis, conducted by the National Patient sparse and we are only seeing the tip of the iceberg. He said that Safety Foundation (NPSF) which is sponsored by the American when errors are specifically sought out, reported rates are Medical Association. (Dr Leape is a founding member of the "distressingly high". He cited several autopsy studies with rates NPSF.) The survey found that more than 100 million Americans as high as 35-40% of missed diagnoses causing death. He also have been impacted directly and indirectly by a medical mistake. commented that an intensive care unit reported an average of 1.7 Forty-two per cent were directly affected and 84% personally errors per day per patient, and 29% of those errors were knew of someone who had experienced a medical mistake." potentially serious or fatal. We wonder: what is the effect on Dr Leape at this press conference also updated his 1994 statis- someone who daily gets the wrong tics, saying that medical errors in in-patient medication, the wrong dose, the wrong hospital settings nationwide, as of 1997, procedure; how do we measure the could be as high as three million and could accumulated burden of injury, and when the cost as much as $200 billion. Leape used a patient finally succumbs after the 10th error 14% fatality rate to determine a medical error that week, what is entered on the death This brings up the death rate of 180,000 in 1994." Using certificate? . nn eape's base number of three million errors, Leape calculated the rate of error in the obvious question: the annual deaths figure for 1997 could be as intensive care unit. First, he found that each who is reporting much as 420,000 for in-patients alone. This patient had an average of 178 "activities" . 0) does not include nursing home deaths or peo- (staff/procedure/medical interactions) a day, medical error: ple in the outpatient community dying of of which 1.7 were errors, which means a 1% drug side effects or as a result of medical failure rate. To some, this may not seem like Usually it is the procedures. much, but, putting this into perspective, . . ' Leape cited industry standards where a patient or the patient s Only a Fraction of Medical Errors 0.1% failure rate would mean: in avia- surviving family. Are Reported tion, two unsafe plane landings per day at [Chicago's] O'Hare airport; in the US Leape, in 1994, said that he was well aware that medical errors were not Mail, 16,000 pieces of lost mail every If no one notices the being reported.'® hour; or in banking, 32,000 bank iti According to a study in two obstet- checks deducted from the wrong bank error, it Is never rics units in the UK, only about one account every hour. reported. quarter of the adverse incidents in the Analysing why there is so much units is ever reported, for reasons of medical error, Leape acknowledged the rotecting staff or preserving reputa- lack of reporting. Unlike a jumbo-jet tions or for fear of reprisals including crash, which gets instant media cover- lawsuits.” age, hospital errors are spread out over An analysis by Wald and Shojania the country in thousands of different 2001] found that only 1.5% of all locations. They are also perceived as adverse events result in an incident isolated and unusual events. However, the most important reason report, and only 6% of adverse drug events are identified proper- that medical error is unrecognised and growing, according to ly. The authors learned that the American College of Surgeons Leape, was—and still is—that doctors and nurses are unequipped gives a very broad guess that surgical incident reports routinely to deal with human error, due to the culture of medical training capture only 5—30% of adverse events. In one surgical study, and practice. only 20% of surgical complications resulted in discussion at mor- Doctors are taught that mistakes are unacceptable. Medical bidity and mortality rounds.” From these studies, it appears that mistakes are therefore viewed as a failure of character, and any all the statistics that are gathered may be substantially underesti- error equals negligence. We can see how a great deal of "sweep- mating the number of adverse drug and medical therapy incidents. ing under the rug" takes place, since nobody is taught what to do _‘ This also underscores the fact that our mortality statistics are actu- when medical error does occur. Leape cited McIntyre and ally conservative figures. Popper, who said that the "infallibility model" of medicine leads An article in Psychiatric Times [Grinfield, April 2000] outlines to intellectual dishonesty with a need to cover up mistakes rather the stakes involved with reporting medical errors.” The author than admit them. There are no grand rounds on medical errors; found that the public is fearful of suffering a fatal medical error, there is no sharing of failures among doctors, and no one to sup- and doctors are afraid they will be sued if they report an error. port doctors emotionally when their error harms a patient. This brings up the obvious question: who is reporting medical Dr Leape hoped his paper would encourage medical practition- error? Usually it is the patient or the patient's surviving family. If ers to "fundamentally change the way they think about errors and no one notices the error, it is never reported. why they occur". It's been almost a decade since this ground- Janet Heinrich, an associate director at the US General breaking work, but the mistakes continue to soar. Accounting Office which is responsible for health financing and One year later, in 1995, a report in JAMA [July 5] said: "Overa _ public health issues, testifying before a House subcommittee on This brings up the obvious question: who is reporting medical error? Usually it is the patient or the patient's surviving family. reported. 20 = NEXUS If no one notices the error, it is never www.nexusmagazine.com AUGUST — SEPTEMBER 2004