Medical Errors

Life is error prone, personally and as a system
How many of you have
   gotten 100% on every test since 1st grade?
   misread instructions or directions?
   never made a mistake?
   showed up, wrong place/wrong time for lack of or poor info?

Threshold of doubt/confidence
   fallen prey to preconceived notion?
   fallen prey to bad advice?
   ignored good advice?
   been confident with your competence?

Life has a pace and pressure
   been tired, distracted, disinterested, not focused?
   been short of time and temper?
   mismanaged your time?

Medical errors occur
   in the Hippocratic oath, "and this above all, do no harm" is
             a goal not a probability or possibility

We learn from our mistakes
   see one, do one, teach one is more accurately
   see one, botch one, do one, teach one
   error correction is at the center of quality improvement programs
   airlines & anesthesia are 6 sigma systems, rest of medicine is 2-3

People die in and from the healthcare system
   US death rate: 2,500,000 year, ~ 1% of population/yr
   Hospitals in US ~ 5000, with ~ 500,000 beds total
   Average death rate in a hospital/yr ~ 1 death/bed/yr
   Thus ~500,000 deaths in hosp/yr
   ~15-20% of patients die in hospitals of an undiagnosed, treatable disease ~100,000.
    Recent press says 44,000 to 99,000 die/yr from medical errors
   Autopsy rate in US ~ 5%
   Thus ~25,000 autopsies/yr in deaths within the hospital &
            ~475,000 deaths in hosp without autopsy

Trelstad RL, Amenta PS, Foran DJ, Smilow, PC. The Role for Regional
Autopsy Centers in the Evaluation of Covered Deaths: Survey of Opinions
of U.S. and Canadian Chairs of Pathology and Major Health Insurers in
the United States. Arch Path Lab Med, 120:753-758, 1996.