Medical Practice & Risks

Medline Articles on Medicine

"Medicine is now a high risk industry, like aviation. But, the chance of dying in an aviation accident is one in 2 million, while the risk of dying from a medical accident is one in 200!" - Dr. Leape of the Harvard School of Public Health

• Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies.
  Lazarou J, Pomeranz BH, Corey PN. Department of Zoology, University of Toronto, Ontario, Canada.
  JAMA 1998 Apr 15;279(15):1200-5
  
  OBJECTIVE: To estimate the incidence of serious and fatal adverse drug reactions (ADR) in hospital patients. DATA SOURCES: Four electronic databases were searched from 1966 to 1996. STUDY SELECTION: Of 153, we selected 39 prospective studies from US hospitals. DATA EXTRACTION: Data extracted independently by 2 investigators were analyzed by a random-effects model. To obtain the overall incidence of ADRs in hospitalized patients, we combined the incidence of ADRs occurring while in the hospital plus the incidence of ADRs causing admission to hospital. We excluded errors in drug administration, noncompliance, overdose, drug abuse, therapeutic failures, and possible ADRs. Serious ADRs were defined as those that required hospitalization, were permanently disabling, or resulted in death. DATA SYNTHESIS: The overall incidence of serious ADRs was 6.7% (95% confidence interval [CI], 5.2%-8.2%) and of fatal ADRs was 0.32% (95% CI, 0.23%-0.41%) of hospitalized patients. We estimated that in 1994 overall 2,216,000 (1,721,000-2,711,000) hospitalized patients had serious ADRs and 106,000 (76,000-137,000) had fatal ADRs, making these reactions between the fourth and sixth leading cause of death. CONCLUSIONS: The incidence of serious and fatal ADRs in US hospitals was found to be extremely high. While our results must be viewed with circumspection because of heterogeneity among studies and small biases in the samples, these data nevertheless suggest that ADRs represent an important clinical issue.
  
  
• To Err is Human: Building a safer health system.
  Institute of Medicine, November 1999
  
  Health care in the United States is not as safe as it should be--and can be. At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented, according to estimates from two major studies. Even using the lower estimate, preventable medical errors in hospitals exceed attributable deaths to such feared threats as motor-vehicle wrecks, breast cancer, and AIDS.
  
  Among the problems that commonly occur during the course of providing health care are adverse drug events and improper transfusions, surgical injuries and wrong-site surgery, suicides, restraint-related injuries or death, falls, burns, pressure ulcers, and mistaken patient identities. High error rates with serious consequences are most likely to occur in intensive care units, operating rooms, and emergency departments.
  
  Beyond their cost in human lives, preventable medical errors exact other significant tolls. They have been estimated to result in total costs (including the expense of additional care necessitated by the errors, lost income and household productivity, and disability) of between $17 billion and $29 billion per year in hospitals nationwide. Errors also are costly in terms of loss of trust in the health care system by patients and diminished satisfaction by both patients and health professionals. Patients who experience a long hospital stay or disability as a result of errors pay with physical and psychological discomfort. Health professionals pay with loss of morale and frustration at not being able to provide the best care possible. Society bears the cost of errors as well, in terms of lost worker productivity, reduced school attendance by children, and lower levels of population health status.
  
  The Quality of Health Care in America Committee of the Institute of Medicine (IOM) concluded that it is not acceptable for patients to be harmed by the health care system that is supposed to offer healing and comfort--a system that promises, “First, do no harm.” Helping to remedy this problem is the goal of To Err is Human: Building a Safer Health System, the IOM Committee’s first report.
  
  In this report, issued in September 1999, the committee lays out a comprehensive strategy by which government, health care providers, industry, and consumers can reduce preventable medical errors. Concluding that the know-how already exists to prevent many of these mistakes, the report sets as a minimum goal a 50 percent reduction in errors over the next five years. In its recommendations for reaching this goal, the committee strikes a balance between regulatory and market-based initiatives, and between the roles of professionals.
  
  
• The HealthGrades Patient Safety in American Hospitals study
  July 27, 2004
  An average of 195,000 people in the U.S. died due to potentially preventable, in-hospital medical errors in each of the years 2000, 2001 and 2002, according to a new study of 37 million patient records that was released today by HealthGrades, the healthcare quality company.
  
  The HealthGrades Patient Safety in American Hospitals study is the first to look at the mortality and economic impact of medical errors and injuries that occurred during Medicare hospital admissions nationwide from 2000 to 2002. The HealthGrades study applied the mortality and economic impact models developed by Dr. Chunliu Zhan and Dr. Marlene R. Miller in a research study published in the Journal of the American Medical Association (JAMA) in October of 2003. The Zhan and Miller study supported the Institute of Medicine’s (IOM) 1999 report conclusion, which found that medical errors caused up to 98,000 deaths annually and should be considered a national epidemic.
  
  The HealthGrades study finds nearly double the number of deaths from medical errors found by the 1999 IOM report “To Err is Human,” with an associated cost of more than $6 billion per year. Whereas the IOM study extrapolated national findings based on data from three states, and the Zhan and Miller study looked at 7.5 million patient records from 28 states over one year, HealthGrades looked at three years of Medicare data in all 50 states and D.C. This Medicare population represented approximately 45 percent of all hospital admissions (excluding obstetric patients) in the U.S. from 2000 to 2002.
  
  “The HealthGrades study shows that the IOM report may have underestimated the number of deaths due to medical errors, and, moreover, that there is little evidence that patient safety has improved in the last five years,” said Dr. Samantha Collier, HealthGrades’ vice president of medical affairs. “The equivalent of 390 jumbo jets full of people are dying each year due to likely preventable, in-hospital medical errors, making this one of the leading killers in the U.S.”
  
  Among the findings in the HealthGrades Patient Safety in American Hospitals study are as follows:
  
  About 1.14 million patient-safety incidents occurred among the 37 million hospitalizations in the Medicare population over the years 2000-2002. Of the total 323,993 deaths among Medicare patients in those years who developed one or more patient-safety incidents, 263,864, or 81 percent, of these deaths were directly attributable to the incident(s). One in every four Medicare patients who were hospitalized from 2000 to 2002 and experienced a patient-safety incident died. The 16 patient-safety incidents accounted for $8.54 billion in excess in-patient costs to the Medicare system over the three years studied. Extrapolated to the entire U.S., an extra $19 billion was spent and more than 575,000 preventable deaths occurred from 2000 to 2002. Patient-safety incidents with the highest rates per 1,000 hospitalizations were failure to rescue, decubitus ulcer and postoperative sepsis, which accounted for almost 60 percent of all patient-safety incidents that occurred. Overall, the best performing hospitals (hospitals that had the lowest overall patient safety incident rates of all hospitals studied, defined as the top 7.5 percent of all hospitals studied) had five fewer deaths per 1000 hospitalizations compared to the bottom 10th percentile of hospitals. This significant mortality difference is attributable to fewer patient-safety incidents at the best performing hospitals. Fewer patient safety incidents in the best performing hospitals resulted in a lower cost of $740,337 per 1,000 hospitalizations as compared to the bottom 10th percentile of hospitals. The complete study, including the list of AHRQ patient-safety indicators, can be found at http://www.healthgrades.com. “If the Center for Disease Control’s annual list of leading causes of death included medical errors, it would show up as number six, ahead of diabetes, pneumonia, Alzheimer’s disease and renal disease,” continued Dr. Collier. “Hospitals need to act on this, and consumers need to arm themselves with enough information to make quality-oriented health care choices when selecting a hospital.”
  
  “If all the Medicare patients who were admitted to the bottom 10th percentile of hospitals from 2000 to 2002 were instead admitted to the “best” hospitals, approximately 4,000 lives and $580 million would have been saved,” said Dr. Collier.
  
  
• Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I.
  Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, Newhouse JP,Weiler PC, Hiatt HH. Division of General Medicine, Brigham and Women's Hospital, Boston, MA 02115.
  N Engl J Med 1991 Feb 7;324(6):370-6
  
  BACKGROUND. As part of an interdisciplinary study of medical injury and malpractice litigation, we estimated the incidence of adverse events, defined as injuries caused by medical management, and of the subgroup of such injuries that resulted from negligent or substandard care. METHODS. We reviewed 30,121 randomly selected records from 51 randomly selected acute care, nonpsychiatric hospitals in New York State in 1984. We then developed population estimates of injuries and computed rates according to the age and sex of the patients as well as the specialties of the physicians. RESULTS. Adverse events occurred in 3.7 percent of the hospitalizations (95 percent confidence interval, 3.2 to 4.2), and 27.6 percent of the adverse events were due to negligence (95 percent confidence interval, 22.5 to 32.6). Although 70.5 percent of the adverse events gave rise to disability lasting less than six months, 2.6 percent caused permanently disabling injuries and 13.6 percent led to death. The percentage of adverse events attributable to negligence increased in the categories of more severe injuries (Wald test chi 2 = 21.04, P less than 0.0001). Using weighted totals, we estimated that among the 2,671,863 patients discharged from New York hospitals in 1984 there were 98,609 adverse events and 27,179 adverse events involving negligence. Rates of adverse events rose with age (P less than 0.0001). The percentage of adverse events due to negligence was markedly higher among the elderly (P less than 0.01). There were significant differences in rates of adverse events among categories of clinical specialties (P less than 0.0001), but no differences in the percentage due to negligence. CONCLUSIONS. There is a substantial amount of injury to patients from medical management, and many injuries are the result of substandard care.
  
  
• The adequacy of medical school education in musculoskeletal medicine.
  Freedman KB, Bernstein J University of Pennsylvania School of Medicine, Philadelphia, USA.
  J Bone Joint Surg Am 1998 Oct;80(10):1421-7
  
  A basic familiarity with musculoskeletal disorders is essential for all medical school graduates. The purpose of the current study was to test a group of recent medical school graduates on basic topics in musculoskeletal medicine in order to assess the adequacy of their preparation in this area. A basic-competency examination in musculoskeletal medicine was developed and validated. The examination was sent to all 157 chairpersons of orthopaedic residency programs in the United States, who were asked to rate each question for importance and to suggest a passing score. To assess the criterion validity, the examination was administered to eight chief residents in orthopaedic surgery. The study population comprised all eighty-five residents who were in their first postgraduate year at our institution; the examination was administered on their first day of residency. One hundred and twenty-four (81 per cent) of the 154 orthopaedic residency-program chairpersons who received the survey responded to it. The chairpersons rated twenty-four of the twenty-five questions as at least important. The mean passing score (and standard deviation) that they recommended for the assessment of basic competency was 73.1 +/- 6.8 per cent. The mean score for the eight orthopaedic chief residents was 98.5 +/- 1.07 per cent, and that for the eighty-five residents in their first postgraduate year was 59.6 +/- 12 per cent. Seventy (82 per cent) of the eighty-five residents failed to demonstrate basic competency on the examination according to the chairpersons' criterion. The residents who had taken an elective course in orthopaedic surgery in medical school scored higher on the examination (mean score, 68.4 per cent) than did those who had taken only a required course in orthopaedic surgery (mean score, 57.9 per cent) and those who had taken no rotation in orthopaedic surgery (mean score, 55.9 per cent) (p = 0.005 and p = 0.001, respectively). In summary, seventy (82 per cent) of eighty-five medical school graduates failed a valid musculoskeletal competency examination. We therefore believe that medical school preparation in musculoskeletal medicine is inadequate.
  
  
• An evaluation of medical school education in musculoskeletal medicine at the University of the West Indies, Barbados.
  Department of Surgery, School of Medicine and Research, University of the West Indies, Cave Hill, Barbados. Jones JK.
  West Indian Med J. 2001 Mar;50(1):66-8.
  
  At the University of the West Indies, Cave Hill campus, the Freedman and Bernstein musculoskeletal competency examination was administered to 22 medical students during the last month of their final year. Eighty-two per cent (82%) of the students failed to score above the passing score of 73.1%. Nineteen of the twenty-two students had taken an orthopaedic elective or rotation during their final two years. The questions were also categorized as Anatomy, Trauma and General Orthopaedics. All students failed to score above the passing score in Anatomy. Sixty-four per cent (64%) failed in Trauma and 45% failed in General Orthopaedics. This study suggests that inadequacies in medical school preparation do exist at this campus of the University of the West Indies and the findings mirror those at medical schools in the United States of America.
  
  
• Educational deficiencies in musculoskeletal medicine.
  Freedman KB, Bernstein J.
  University of Pennsylvania School of Medicine, Philadelphia, 19104, USA.
  J Bone Joint Surg Am. 2002 Apr;84-A(4):604-8.
  
  BACKGROUND: We previously reported the results of a study in which a basic competency examination in musculoskeletal medicine was administered to a group of recent medical school graduates. This examination was validated by 124 orthopaedic program directors, and a passing grade of 73.1% was established. According to that criterion, 82% of the examinees failed to demonstrate basic competency in musculoskeletal medicine. It was suggested that perhaps a different passing grade would have been set by program directors of internal medicine departments. To test that hypothesis, and to determine whether the importance of the individual questions would be rated similarly, the validation process was repeated with program directors of internal medicine residency departments as subjects. METHODS: Our basic competency examination was sent to all 417 program directors of internal medicine departments in the United States. Each recipient was mailed a letter of introduction explaining the purpose of the study, a copy of the examination, and our answer key and scoring guide. There was no mention of the results of the first study. The subjects were requested to rate the importance of each question on the same visual analog scale, ranging from "not important" to "very important," as had been used by the orthopaedic program directors. These ratings were converted into numerical scores. The program directors were also asked to suggest a passing score for the examination, and this score was used to assess the examinees' performance on the examination. The results on the basis of the internal medicine program directors' responses and those according to the orthopaedic program directors' responses were compared. RESULTS: Two hundred and forty (58%) of the 417 program directors of internal medicine residency departments responded. They suggested a mean passing score (and standard deviation) of 70.0% +/- 9.9%. As reported previously, the mean test score of the eighty-five examinees was 59.6%. Sixty-six (78%) of them failed to demonstrate basic competency on the examination according to the criterion set by the internal medicine program directors. The internal medicine program directors assigned a mean importance score of 7.4 (of 10) to the questions on the examination compared with a mean score of 7.0 assigned by the orthopaedic program directors. The internal medicine program directors gave twenty-four of the twenty-five questions an importance score of at least 5 and seventeen of the twenty-five questions an importance score of at least 6.6. CONCLUSIONS: According to the standard suggested by the program directors of internal medicine residency departments, a large majority of the examinees once again failed to demonstrate basic competency in musculoskeletal medicine on the examination. It is therefore reasonable to conclude that medical school preparation in musculoskeletal medicine is inadequate.