When patients die in hospital, is it because their are unlucky or is it due to medical error?

Reflecting on the 15th anniversary of Institute of Medicine’s 1999 report, “To Err is Human”, Maryanne McGuckin, Dr.ScEd, FSHEA recently wrote:

We have seen some gains in preventing certain infections, for example, central-line catheter infections have been reduced by 80 percent across the country and don’t even happen in some hospitals. Yet we still have 120 adverse events per 100,000 hospital admissions each year. Each year, there are 4,000 surgical near-misses or adverse events, such as wrong-site surgery, the wrong procedure, or sponges left in a patient.

Every preventable adverse event reflects an unnecessary death or injury. Leaders of various agencies have spent 15 years forming committees, generating guidelines, and mandating public reporting, all at a cost to each of us but with poor outcomes.

This failure is due to the fact there is not adequate agreement, consensus, or validation for our measurement process.

Hats off to @LeapfrogGroup for tweeting about this!

Contrast this statement with the decision by the Centers for Medicare & Medicaid Services (CMS) to take into account luck in its public scorecards – HospitalCompare and PhysicianCompare – following a New York Times article on luck. Writes Michael Millenson:

“For years, doctors have said, ‘The operation was a success, but the patient died,’” explained CMS spokesman Nick “the Greek” Stephanopoulos. “We decided they were right.”

Stephanopoulos said “luck” could also explain why as many as 400,000 patients die each year from so-called “preventable” medical errors in hospitals, even though it’s widely known that Americans get the best possible medical care.

So, what do you think – When patients die in hospital, is it because their are unlucky or is it due to medical error?

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