From: deputydog23x@gmail.com   
      
   Deaths by medical mistakes hit records    
      
   July 18, 2014 | Erin McCann - Managing Editor    
   POSTED IN: Quality and Safety, Policy and Legislation, Clinical    
      
      
      
   It's a chilling reality - one often overlooked in annual mortality statistics:   
   Preventable medical errors persist as the No. 3 killer in the U.S. - third   
   only to heart disease and cancer - claiming the lives of some 400,000 people   
   each year. At a Senate    
   hearing Thursday, patient safety officials put their best ideas forward on how   
   to solve the crisis, with IT often at the center of discussions.    
        
   Hearing members, who spoke before the Subcommittee on Primary Health and   
   Aging, not only underscored the devastating loss of human life - more than   
   1,000 people each day - but also called attention to the fact that these   
   medical errors cost the nation a    
   colossal $1 trillion each year.      
        
   "The tragedy that we're talking about here (is) deaths taking place that   
   should not be taking place," said subcommittee Chair Sen. Bernie Sanders,   
   I-Vt., in his opening remarks.    
        
   [See also: EHR adverse events data cause for alarm.]    
        
   Among those speaking was Ashish Jha, MD, professor of health policy and   
   management at Harvard School of Public Health, who referenced the Institute of   
   Medicine's 1999 report To Err is Human, which estimated some 100,000 Americans   
   die each year from    
   preventable adverse events.    
        
   "When they first came out with that number, it was so staggeringly large, that   
   most people were wondering, 'could that possibly be right?'" said Jha.    
        
   Some 15 years later, the evidence is glaring. "The IOM probably got it wrong,"   
   he said. "It was clearly an underestimate of the toll of human suffering that   
   goes on from preventable medical errors."    
        
   It's not just the 1,000 deaths per day that should be huge cause for alarm,   
   noted Joanne Disch, RN, clinical professor at the University of Minnesota   
   School of Nursing, who also spoke before Congress. There's also the 10,000   
   serious complications cases    
   resulting from medical errors that occur each day.    
        
   Disch cited the case of a Minnesota patient who underwent a bilateral   
   mastectomy for cancer, only to find out post surgery a mix-up with the biopsy   
   reports had occurred, and she had not actually had cancer.    
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                   "Medicine today invests heavily in information technology, yet   
   the promised    
                 improvement in patient safety and productivity frankly have not   
   been realized."    
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
                                                                                    
   - Peter Pronovost, MD    
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   In terms of how to address this crisis, the recommendations put forth were   
   diverse - including boosting the number of registered nurses, supporting AHRQ,   
   CDC and establishing incentives. There did, however, exist common agreement   
   with one thing:    
   information technology is falling short in many arenas.    
        
   "Medicine today invests heavily in information technology, yet the promised   
   improvement in patient safety and productivity frankly have not been   
   realized," said Peter Pronovost, MD, senior vice president for Patient Safety   
   and Quality and director of the    
   Armstrong Institute for Patient Safety and Quality at Johns Hopkins.    
      
   Peter Pronovost, MD    
        
   Jha agreed. There's been so much hype around electronic health records, with   
   the industry showing "phenomenal progress" with adoption and use. "But the   
   potential is not going to be realized unless those tools are really focused on   
   improving patient    
   safety," he said. "The tools themselves won't automatically do it."    
        
   Tejal Gandhi, MD, president of the National Patient Safety Foundation, added:   
   The IT needs to be improved. "We need better systems to minimize cognitive   
   errors...such as computerized algorithms," she said, speaking on behalf of   
   ambulatory patient safety.    
        
   One of the more significant issues relating to ambulatory medical errors   
   involves missed and delayed diagnoses, she pointed out, for instance failing   
   to order appropriate tests or initiate follow up. The IT systems, she   
   continued, need to be designed to    
   better manage test results.    
        
   And other key recommendations?    
        
   [See also: CDC on EHR errors: Enough's enough.]    
        
   Jha pointed out: Data and metrics are key.    
        
   "If you don't have data and metrics, you don't know how you're doing; you   
   don't know how you compare to anyone else, and you have no way to judge   
   whether your efforts are making a difference or not," he said.    
        
   Jha advocated on behalf of giving the Centers for Disease Control and   
   Prevention the job of collecting and monitoring this data.    
        
   Pronovost agreed, as currently, there exists no "guarantee that the measures   
   that we're reporting are accurate," he said.    
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                  "What these numbers say is that every day, a 747, two of them   
   are crashing."    
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   For instance, he referenced the time when Johns Hopkins was both congratulated   
   and criticized for its performance on blood stream infections, pertaining to   
   the same measures and the same time period. "The one we're paid on using   
   administrative data, got    
   it right 13 percent of the time," he said.    
      
   "Why is it when a death happens one at time, silently, it warrants less   
   attention than when deaths happen in groups of five or 10?" he asked. "What   
   these numbers say is that every day, a 747, two of them are crashing. Every   
   two months, 9-11 is occurring..   
   .we would not tolerate that degree of preventable harm in any other forum."    
        
   In the hearing's closing questions, when Sanders inquired as to why this   
   crisis was not constantly splashed across front page news, he was met with   
   this: "When people go to the hospital, they are sick. It is very easy to   
   confuse the fact that somebody    
   might have died because of a fatal consequence of their disease, versus they   
   died from a complication from a medical error," Jha said. "It has taken a lot   
   to prove to all of us that many of these deaths are not a natural consequence   
   of the underlying    
   disease. They are purely failures of the system."    
      
      
      
      
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