Medical Errors: A Leading Cause of Death in the United States

By: Abhas Gupta

Even as medical students, we routinely observe errors being made by our mentors—the residents, fellows, and attendings charged with cultivating our professional skill. Many medical errors are caught later in the care-cycle and others persist undetected. From our vantage point, only rarely do these errors place the patient in severe discomfort and almost never do these errors result in a patient's death. On the contrary, a 2004 study conducted by HealthGrades indicates that the issue is much more grave than we think: preventable medical errors result in 195,000 deaths annually.

The cost of medical errors is equally alarming. Adverse drug-related events, on average, extend a patient's hospital stay by 4.6 days and increase a patient's hospital bill by $4,685. Post-operative infections can cost over $57,000 per patient and re-opened wounds can cost over $40,000 per patient.

Several studies indicate that the medical errors problem may be even worse abroad. "Adverse medical events are estimated to be between 10.6 and 16.6 percent in Australia, between 10 and 11.7 percent in the United Kingdom, and about 9 percent in Denmark, versus in the range of 3.2 and 5.4 percent in the United States" (Porter). This transnational discrepancy may be attributed to the aggressive malpractice litigation in the United States; however, such an environment promotes "doctors to practice 'defensive' medicine in the form of unnecessary tests, overdiagnosis, and redundant or unnecessary treatment", further driving up the cost of health care. The practice of "defensive" medicine is still unable to limit medical errors to an acceptable rate. Moreover, additional cost in the United States is not correlated with better quality. A 2006 study by the Pennsylvania Health Care Cost Containment Council showed a significant difference in fees for coronary bypass surgeries between small and large hospitals ($20,000 vs. $100,000, on average) with no significant differences in lengths of stay or mortality rates.

The factors contributing to the prevalence of medical errors are broad and largely structural. Our current system of care places a tremendous burden on physicians, making medical errors predictable but, fortunately, preventable. Correcting these structural flaws will require a dramatic change in the fundamental elements of our health care system. Some of the structural flaws in American health care are listed below:

• Inadequate financial incentives - provider reimbursement is presently based on services rendered, implicitly discouraging providers from improving quality and minimizing mistakes. A 1999 publication by the Institute of Medicine entitled, "To Err is Human: Building a Safer Health Care System", spurred an effort to reward quality called pay for performance. Although a step in the right direction, this effort is criticized as being "pay for compliance" (providers are additionally reimbursed based on government-defined treatment criteria) and does not do enough to spur improvement beyond the criteria


• Decentralized care - the divvying of care to general practitioners and multiple specialists inevitably introduces errors in the absence of a well thought-out system of interoffice communication. Moreover, patient charts can lack a consistent organizational structure. Important details can be easily obfuscated and identifying potential adverse effects is left to the capacity of individual caregivers. Electronic medical records coupled with intelligent (automated) warning systems could greatly minimize these errors


• Slow-adoption of clinical trials results - "it takes, on average, seventeen years for the results of clinical trials to become standard clinical practice" (Porter). Eliminating the disincentives to improve the quality of care will immediately improve the rate of adoption


• Poor standardization of care - in every other industry, repetition results in increased quality, increased efficiency, and decreased cost. Unfortunately, best-practices adoption in American health care is notoriously slow. The recent discussion of launching a national commission dedicated to disseminating best practices should significantly decrease the incidence of medical errors

Michel Porter accurately states that "attempting to require participants in the system to behave contrary to their interests is futile." As future physicians, our best interests are served by educating ourselves on the misaligned incentives in American health care and advocating for not just short-sighted, stop-gap measures but for long-term, effective change.

References:
1. Porter, M. E., Teisberg, E. O. Redefining health care: creating value-based competition on results. Boston, MA: Harvard Business School Press, 2006.
2. Gratzer, D. The Cure: How Capitalism Can Save American Health Care. New York, NY: Encounter Books, 2006.