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Challenge 2: Medical Errors

    Medical errors, defined as a preventable adverse event or effect of care, are a leading cause of death in the United States—exceeding deaths attributable to motor vehicle accidents,1 breast cancer,2 and heart failure.3 They include inaccurate or incomplete diagnosis or treatment, as well as when an appropriate method of care is executed incorrectly.4 Human error has been implicated in nearly 80 percent of adverse events that occur in complex healthcare systems. The vast majority of medical errors result from faulty systems and poorly designed processes versus poor practices or incompetent practitioners.5

    First credited with initiating an industry-wide call to improve patient safety, a 2000 Institute of Medicine (IOM) report, “To Err is Human: Building a Safer Health System,” estimated that medical errors result in between 44,000 and 98,000 preventable deaths and 1,000,000 excess injuries each year in U.S. hospitals.6 Most of the errors cited in the IOM report were due to problems in the health care system rather than individual failures.

    A 2006 follow-up to the IOM study found that medication errors are among the most common medical mistakes, harming at least 1.5 million people every year. In 2000 alone, the extra medical costs incurred by preventable drug related injuries approximated $887 million—and the study looked only at injuries sustained by Medicare recipients, a subset of clinic visitors.7

    In the United States, reporting medical errors in hospitals is a condition of payment by Medicare. However, an investigation by the Office of Inspector General, Department of Health and Human Services released January 6, 2012, found that most errors are not reported and even in the case of errors that are reported and investigated changes are seldom made which would prevent them in the future.8

    At the Patient Safety, Science & Technology Summit, an expert panel will review a variety of approaches that are available immediately for hospitals committed to reducing medical errors and patient harm, including automated infusion technologies, integration of electronic medical records, continuous patient monitoring, infusion pumps, predictive algorithms, checklists, and process of care advances. The panel will also explore the potential impact of medical device interoperability and information sharing for medical error reduction.

    1. U.S. Census Bureau. “Statistical Abstract of the United States: 2012.” Table 1103. Motor Vehicle Accidents—Number and Deaths: 1990-2009.
    2. American Cancer Society. “Cancer Facts & Figures 2012.”
    3. Centers for Disease Control and Prevention. “National Vital Statistics Report; Deaths: Final Data for 2009.”
    4. Timothy P. Hofer, MD (November 2000). What Is an Error? Effective Clinical Practice (American College of Physicians).
    5. Palmieri, P. A., DeLucia, P. R., Ott, T. E., Peterson, L. T., & Green, A. (2008). “The anatomy and physiology of error in averse healthcare events”. Advances in Health Care Management. Advances in Health Care Management 7: 33—68. doi:10.1016/S1474-8231(08)07003-1. ISBN 978-1-84663-954-8.
    6. Institute of Medicine (2000). “To Err Is Human: Building a Safer Health System (2000)”. The National Academies Press.
    7. “Medication Errors Injure 1.5 Million People and Cost Billions of Dollars Annually”. The National Academy of Science. 2006.
    8. Summary “Hospital Incident Reporting Systems Do Not Capture Most Patient Harm” Report (OEI-06-09-00091) Office of Inspector General, Department of Health and Human Services, January 6, 2012.