The title above comes from a May 3, 2016, paper published in the prestigious British Medical Journal. The study was also reported on by a number of news outlets and articles.
According to study author Dr. Martin Makary, surgical director of the Johns Hopkins Multidisciplinary Pancreas Clinic and a professor of surgery at Johns Hopkins Medicine, Medical error has been defined as an unintended act (either of omission or commission) or one that does not achieve its intended outcome,3 the failure of a planned action to be completed as intended (an error of execution), the use of a wrong plan to achieve an aim (an error of planning),4 or a deviation from the process of care that may or may not cause harm to the patient.
The paper notes that many times medical error is not listed as the cause of death because there was no specific code for the event. Additionally, if an error leads to a fatal heart attack, the cause of death will most likely be listed as a heart attack.
In a May 4, 2016, CBS News article on this subject, Dr. Makary explained that there is very little funding for research to decrease medical errors. One of the big issues that we in the patient safety research field face, that we run up against, is a problem where there’s very little funding for research in making care safer and better. Part of the problem is that our national funding is informed from our national health statistics. But those statistics don’t recognize medical care gone awry as a cause of death.
In a May 3, 2016, Washington Post article, Kenneth Sands, director of health-care quality at Beth Israel Deaconess Medical Center, an affiliate of Harvard Medical School, noted that the problem is not getting better. The overall numbers haven’t changed, and that’s discouraging and alarming.
In comparing medical care to the airline industry, Sands commented that airlines have a much stricter standardization of procedure compared to medical care. There has just been a higher degree of tolerance for variability in practice than you would see in other industries.
In his paper, Dr. Makary offered steps on how to combat this problem by stating, Human error is inevitable. Although we cannot eliminate human error, we can better measure the problem to design safer systems mitigating its frequency, visibility, and consequences. Strategies to reduce death from medical care should include three steps.
The three remedies laid out by Dr. Makary are:
- Making errors more visible when they occur so their effects can be intercepted.
- Having remedies at hand to rescue patients.
- Making errors less frequent by following principles that take human limitations into account.
Using the airline analogy, Dr. Makary said, When a plane crashes, we don’t say this is confidential proprietary information the airline company owns. We consider this part of public safety. Hospitals should be held to the same standards.
In the conclusion of the CBS News article, Dr. Makary sums up the issue by pointing out, We’ve spent a tremendous effort tracking cancer, by state, by subtype, and we report all that to our national cancer registry. But we don’t do any of that for people who die of medical error gone wrong.
