As many as 98,000 Americans die unnecessarily every year from medical mistakes made by physicians, pharmacists and other health care professionals, according to an independent report released yesterday that calls for a major overhaul of how the nation addresses medical errors.
More Americans die from medical mistakes than from breast cancer, highway accidents or AIDS, according to the report from the Institute of Medicine, an arm of the National Academy of Sciences. Those deaths, along with serious nonfatal reactions to other medical errors, cost the nation as much as $29 billion a year, the congressionally chartered research group concluded.
Yet while other areas of the U.S. economy have coordinated safety programs that collect and analyze accident trends, including those that track nuclear reactor accidents, highway crashes and airline disasters, there is no centralized system for keeping tabs on medical errors and using that information to prevent future mistakes.
If such a system were put in place, the report predicts, the number of deaths from medical mistakes could be cut in half within five years.
"These stunningly high rates of medical errors, resulting in deaths, permanent disability and unnecessary suffering, are simply unacceptable in a medical system that promises first to 'do no harm,' " said William C. Richardson, president of the W.K. Kellogg Foundation and chairman of the expert committee that compiled the blunt, 223-page report.
Several medical and public policy organizations have addressed the issue of medical errors since the widely reported death of Boston Globe health columnist Betsy Lehman, who died from a chemotherapy overdose in 1995. But experts said the prestige of the National Academy of Sciences, and in particular its specific proposal to create a federal office to oversee medical accident trends and devise strategies for prevention, could spur real change.
"There's not a controversy here," said David Eddy, a senior adviser to the Pasadena-based health maintenance organization Kaiser Permanente Southern California and an expert in evidence-based medicine. "It's an ideal opportunity to increase quality and decrease costs."
Medical errors can range from a simple miscommunication about a drug's name during a telephone call between a doctor and a nurse to the erroneous programming of a complex medical device at the end of a busy hospital night shift. They include wrong diagnoses from mislabeled blood tubes, mistaken treatments because of poorly labeled drugs, improper dosing because of faulty calculations and a simple lack of communication as a patient gets passed from one provider to the next.
To address the wide range of problems, the report calls for mandatory federal reporting requirements for serious medical accidents. And it calls upon Congress to create and fund a national patient safety center within the Department of Health and Human Services, which would be charged with developing better systems for tracking and preventing patient injuries.
The report also suggests that minor medical errors that have not resulted in serious injuries or death be collected in a confidential database, not available for public review. The hope is that by reducing health care providers' legal exposure and the risk of lawsuits, doctors, hospitals and others may be more open about their errors, and thus give the nation a chance to learn from their mistakes.
"Safety is a cultural matter, and unless you create a cultural environment in which it becomes safe to talk about errors and near misses, you can't get to work on the root causes of error," said Donald M. Berwick, a Harvard professor of health care policy and president of the Institute for Healthcare Improvement, a not-for-profit educational and research organization, who was one of 19 experts who worked on the report.
"You can't use fear or blaming of individuals as a foundation for safety improvement," Berwick said. "We want to set up an environment where more errors will be revealed."
The report concludes that most errors are not the result of flagrant recklessness but occur because of the cumulative opportunities for human error that arise in today's complex medical system. Most are medication errors, Berwick said. "People get the wrong drug or the wrong dose or they get it at the wrong time or it's given to the wrong patient."
Part of the problem is that many new drugs have similar names, which are easily confused when orders are given by voice or are handwritten.
"Physician handwriting has traditionally not been something that has been looked upon highly by calligraphers," said Peter Honig, deputy director of the Food and Drug Administration's office of postmarketing drug risk assessment, the federal unit responsible for tracking medication errors.
Within the past year, Honig said, the FDA has created a "medical errors group" with the explicit job of preventing medication errors. The team reviews new package designs and proposed names for new drugs to make sure they are not too similar to existing ones. In some cases, companies are also addressing the problem, Honig said. Recent ads in medical journals from the makers of the arthritis drug Celebrex, for example, warn doctors not to confuse their product with the anti-seizure drug Cerebyx or the antidepressant Celexa.
Most serious mistakes occur in busy settings such as emergency rooms and intensive care units, according to the report. In some cases they occur because medicines are kept in stock at concentrations known to be toxic, when they probably should be stored in the diluted forms in which they are intended to be given.
Medical errors may be the fifth-leading cause of death.
1.Heart disease 727,000
4.Obstructive lung disease 109,000
5.Medical errors 98,000
6.Accidents/adverse effects 96,000
7.Pneumonia and influenza 86,000
10. Kidney disease 25,000
SOURCES: Institute of Medicine, Centers for Disease Control and Prevention.