Who Believes That Medical Error Is the Third Leading Cause of Hospital Deaths?

Laura A. Stokowski, RN, MS

Disclosures

May 26, 2016

Cause of Death: Medical Error?

While medical error is not a new topic, it is still a difficult one to address, in large part owing to the lack of both a succinct definition and data on the frequency and consequences of error in healthcare. Death certificates don't have a checkbox for "medical error" as a cause or contributing factor in a patient's death.

In 1999, the Institute of Medicine (IOM) published a landmark report[1] on error in healthcare, concluding that medical care was responsible for 44,000-98,000 deaths annually in the United States. In the intervening years, several analyses have suggested that the IOM's figures rather significantly underestimated the problem. Studies[2,3,4,5] published after 1999 estimate that 130,000-575,000 annual inpatient deaths are attributable to medical error.

Using studies published since the 1999 IOM report, Makary and Daniel extrapolated annual inpatient death rates from those reports to the total number of US hospital admissions in 2013, publishing their findings in the British Medical Journal.[6] They calculated that 251,454 inpatients (9.5%) die annually as a result of medical error.[7] "If medical error was a disease," they concluded, "it would rank as the third leading cause of death in the United States," after heart disease and cancer.

Medscape Medical News covered this analysis with the headline "Medical Error is Third Leading Cause of Death in US." Subsequently, more than 500 Medscape readers expressed everything from frank disbelief to admonishment for dissemination of the study's findings. Readers who found the study results credible and thought-provoking were decidedly in the minority. And although the comments often drifted into the realm of "everything that is wrong with healthcare today," the debate shines a light on a critical healthcare issue. [Note: Comments have been edited for clarity and length.]

Everything but the Kitchen Sink

Makary and Daniel noted that a "medical error" may or may not cause harm to the patient and defined an error as:

  • An unintended act (either of commission or omission);

  • An act that does not achieve its intended outcome;

  • The failure of a planned action to be completed (an error of execution);

  • The use of a wrong plan to achieve an aim (an error of planning); or

  • Deviation from the process of care.

However, for this analysis, Makary and Daniel focused not on all medical error but on preventable lethal events.

The most frequent—though diametrically opposed—opinions offered by those who commented was that Makary and Daniel's definition of medical error was either too broad or not broad enough. An orthopedic surgeon wrote, "Just like the original To Err is Human, we are failing to properly distinguish between an error and a complication." This was echoed by an anesthesiologist, who wrote, "Hospital-acquired infection and pulmonary embolism were considered medical errors. While some can be attributed to care, many of these complications are unavoidable patient-related comorbidities." Likewise, a surgeon said, "There is a world of difference between error, bad results, and unintended consequences." A plastic surgeon agreed, writing that "what they considered errors are maloccurrences and complications with disappointing results that are unavoidable."

Others pointed out that the term "medical error" is misleading, because it implies "physician error." They argue that a more appropriate term is "healthcare error,” because many different types of healthcare providers commit errors. Several readers believe that the category of medical error should be expanded to include "patient error." One physician wrote, "If medical error should be listed as a cause of death, then so too should patient error, or lifestyle error—namely, inhaled nicotine, overeating, sedentary living, and alcohol ingestion."

A pain management physician agreed, asking,

How much morbidity and mortality can be explained by the patients themselves? How much bad behavior leads to cardiovascular disease and cancer? How many die from guns and drugs? You will quickly learn that the main source of patient mortality is from the decisions and actions patients take that result in their own demise.

One physician suggested that "medical procedures should be like Olympic diving where they assign a 'degree of difficulty' to each attempt. There is a big difference between attempting something difficult on a risky patient (when something could go wrong) and making a bone-headed belly flop and amputating the wrong leg."

An anesthesiologist asks, "If a patient presents with acute coronary syndrome in cardiogenic shock, is taken immediately to the cath lab, and receives appropriate stenting, but because of the severity of the disease and limitations of current technology, the patient expires, is that considered a medical error?"

A neonatologist concurred with this logic. "That was one of the problems with the original IOM report—they overcounted causality, based simply on the presence of error."

A cardiologist maintained that the known complications of surgeries and procedures should not be classified as medical errors, saying:

Clearly, surgery on the wrong part of the body, receiving the incorrect medication, or missing a diagnosis that is evident on a lab test or imaging study is a medical error. But what about the complications from a procedure? Consider this scenario: A patient with infection risk factors of poorly controlled diabetes and end-stage renal disease on hemodialysis underwent a life-saving procedure, developed an infection, became septic, and succumbed to the infection. Should this be considered a medical error? Unless there is an egregious fault in thinking or performance, or a trend for a certain practitioner or facility to have a significantly higher rate of complications, then I find it difficult (and irresponsible) to label these events "medical errors."

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