The Department of Veterans Affairs' first comprehensive study of problems with patient care at VA hospitals across the country documented nearly 3,000 cases of medical mistakes or "adverse events" involving more than 700 patients who died while hospitalized or shortly thereafter.
About a third of those patients, suffering from depression or terminal illnesses, committed suicide, according to the study, whose details were confirmed by department officials yesterday. But many other deaths were more directly linked to errors by nurses or doctors--such as prescribing or dispensing the wrong drugs, surgery on the wrong body parts, improper insertion of catheters and feeding tubes, and patient abuse.
The deaths occurred between June 1997 and December 1998, during the first 19 months of a policy that requires hospital staff and employees to report medical error. The study is part of a larger effort by VA officials to identify and correct "systemic" care problems in its sprawling hospital network that for years have contributed to patient suffering and death.
The study comes on the heels of an independent report released last month showing that as many as 98,000 Americans die every year as a result of medical mistakes by physicians, pharmacists and other health care professionals. More Americans die from medical mistakes than from breast cancer, highway accidents or AIDS, according to the report by the Institute of Medicine, an arm of the National Academy of Sciences.
President Clinton has announced steps to curb dangerous medical errors, including a requirement that all 300 health plans insuring federal workers adopt new safeguards to avoid accidents that can injure or kill patients.
In contrast with past VA practices of trying to cover up or minimize patient care problems, hospital administrators are now encouraging employees to step forward and fully disclose mistakes as a means of enhancing patient safety.
"We learned you have to have a reporting system where people can report without fear of punishment," said James P. Bagian, head of the Veterans Affairs Department's National Center for Patient Safety. "Then you can say what are the systemic problems."
In the process, officials say, hospital administrators are developing innovative ways to prevent accidental deaths, such as implementing a new bar-code system for administering and monitoring patients' medication and early intervention and counseling for patients to try to prevent suicides.
The VA's comprehensive self-examination, reported yesterday by the New York Times, suggests what could be expected if all hospitals had to report their errors, as recommended recently by the National Academy of Sciences.
Thomas L. Garthwaite, the Clinton administration's acting undersecretary for health, said there is no indication that the incidence of medical errors at VA hospitals is greater than at private hospitals.
"If the impression people are left with [from the VA study] is you have an unsafe system, there is no data to suggest that," Garthwaite said. "What we're doing is trying to fix the problems and we're willing to share information on mistakes."
According to the VA report, there is a wide range of "adverse events." For example, about 540 patients were injured in falls at veterans hospitals and nursing homes, including 44 who died. Also, 277 patients committed suicide at veterans hospitals or shortly after they were discharged, while 476 patients tried to kill themselves but survived.