Editor’s Note: This is the first in a series of posts on ‘Patient Safety’ and specifically the NMP (“not my patient, not my problem”) problem in medicine.
I recently participated in the World Patient Safety Day in Washington, D.C., September 17th, 2024, with organizing founding members of the Patients for Patient Safety, U.S., an affiliate of WHO (World Health Organization). We marched, then gathered for a ‘remembrance ceremony‘ for those lost, harmed or disabled due to medical error(s).
The event is introduced by Martin J Hatlie, JD, President & CEO, Project Patient Care for Patients for Patient Safety Day D.C.:
The first post sets context for the series framing the nature of the problem and range of suggested solutions. Additional context for the series can be found at EndNMP.org
In 2016, a controversial study published in the British Medical Journal (BMJ) “Medical error—the third leading cause of death in the US” suggested that medical errors were the third leading cause of death in the United States, claiming over 250,000 lives annually. This statistic sent shockwaves through the medical community and sparked intense debate about both the accuracy of the number and the methodologies used to arrive at such estimates. Seven years later, we’re still grappling with the fundamental question: How many Americans actually die from medical errors each year?
The Current Landscape
Truth be told, we don’t know the exact number of deaths attributable to medical error(s) – and that’s part of the problem. Current estimates vary widely, ranging from 22,000 to over 440,000 (and above) deaths annually, reflecting the significant challenges in measurement and classification. The Centers for Disease Control and Prevention (CDC) doesn’t require reporting of medical errors on death certificates, and there’s no standardized methodology for capturing this data.
Why Such Wide Variations?
Several factors contribute to the dramatic range in estimates:
1. Definition Discrepancies: There’s no universal definition of what constitutes a medical error. Some studies include only clear mistakes, while others encompass broader categories of preventable harm.
2. Reporting Mechanisms: Death certificates, the primary source for mortality statistics, don’t have a standardized way to indicate medical error as a cause of death.
3. Detection Challenges: Many errors go unnoticed or are not documented due to fear of litigation or professional repercussions.
Current Methodologies and Their Limitations
1. Global Trigger Tool (GTT) – Is a methodology developed by the Institute for Healthcare Improvement (IHI) to identify adverse events in medical records. It uses “triggers” (or clues) to identify possible adverse events, which are then investigated further to determine if an actual adverse event occurred.
Pros:
– Systematic approach using specific criteria
– Can identify errors that might otherwise go unnoticed
Cons:
– Labor-intensive and time-consuming
– Subject to reviewer interpretation
– May not capture all types of errors
2. Voluntary Reporting Systems
Pros:
– Can provide detailed information about specific incidents
– Helps identify patterns and systemic issues
Cons:
– Severe underreporting due to voluntary nature
– Bias towards more obvious or serious errors
3. Retrospective Chart Review
Pros:
– Comprehensive examination of patient records
– Can identify patterns and contributing factors
Cons:
– Time-consuming and expensive
– Subject to hindsight bias
– Limited by quality of documentation
The Case for Accurate Measurement
Despite definitional, measurement and reporting challenges, there are compelling reasons to pursue more accurate measurement of deaths from medical errors:
1. Patient Safety Improvement: Accurate data can help identify patterns and systemic issues, leading to targeted interventions and improved safety protocols.
2. Resource Allocation: Better data can inform where to focus quality improvement efforts and resources.
3. Accountability: Accurate measurement can drive accountability and motivate healthcare organizations to prioritize safety.
The Counterargument
Some argue that focusing too heavily on exact numbers could be counterproductive:
1. Defensive Medicine: Fear of being labeled as ‘error-prone‘ might lead to overly cautious medical practices and only reinforce what some referred to as the ‘blue wall of silence’, ie,, ‘thou shall not speak ill of one’s peers’.
2. Morale Impact: Constant focus on errors could demoralize healthcare workers and impact recruitment. ‘Clinical burnout‘ is already an epidemic for our often over worked and under supported clinicians.
3. Resource Diversion: Time and resources spent on measurement might be better used for direct patient care improvements and learnings from review of suboptimal outcomes, care gaps or poor handoffs during shift changes, etc.
Potential Solutions
Short-term Improvements
1. Standardized Definitions: Develop and implement consistent definitions of medical errors across healthcare systems.
2. Enhanced Reporting Systems: Create protected, anonymous reporting systems to encourage more accurate documentation.
3. Death Certificate Reform: Add specific fields for recording medical errors as contributing factors to death.
Long-term Strategies
1. AI and Machine Learning: Develop sophisticated algorithms to detect potential errors in real-time and analyze patterns across large datasets.
2. Culture Change: Foster an environment where error reporting is seen as a learning opportunity rather than a punitive measure.
3. National Database: Create a standardized, national system for recording and analyzing medical errors.
The Role of Technology
Emerging technologies offer promising solutions for more accurate measurement:
1. Natural Language Processing: Can analyze medical records to identify potential errors that human reviewers might miss.
2. Blockchain: Could provide secure, immutable records of medical events, making it easier to track and analyze errors.
3. Big Data Analytics: Can identify patterns and risk factors across large populations, potentially predicting and preventing errors before they occur.
Conclusion
While perfect measurement of deaths from medical errors may be an unrealistic goal, significant improvements are both possible and necessary. The path forward likely involves a combination of technological solutions, policy changes, and cultural shifts in the medical community.
As we work towards better measurement, we must balance the need for accuracy with the potential negative impacts of excessive focus on errors. The ultimate goal should be to create a healthcare system where errors are promptly identified, openly discussed, and systematically addressed – not to assign blame, but to save lives.
By taking a thoughtful, balanced approach to this challenge, we can work towards a healthcare system that is both more accountable and more effective at preventing harmful errors.
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*Note to readers: This blog post aims to provide a balanced overview of a complex issue. The statistics and methodologies discussed are based on currently available research, but given the nature of the topic, exact numbers remain subject to debate and ongoing study.*
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