By Richard Knox
Some years back, my 78-year-old father suddenly collapsed with kidney and liver failure. He had no prior kidney or liver disease. Several doctors told us what happened.
The catastrophe was caused by his use of a medication called Pyridium for several months. It was prescribed to relieve bladder pain caused by radiotherapy treatments for Dad’s prostate cancer, which was localized and thought to be curable.
The package insert for Pyridium warns it shouldn’t be taken for longer than two days and elderly patients taking it should be monitored carefully for signs of liver and kidney failure. In Dad’s case, the prescription was renewed three times over a two-month period by two different doctors — who did not order any kidney or liver function tests.
It was a clearly avoidable error. “This has been an eye-opener to me,” one of his doctors told me during a conversation in the intensive care unit where Dad lay dying.
That was in 1989. Five years later, Boston Globe health columnist Betsy Lehman died of a chemotherapy overdose at Dana-Farber Cancer Institute — a medical error I documented extensively for the Globe. That tragedy, perhaps the nation’s iconic medical mistake, is credited with launching a national movement to prevent medical errors.
I’d like to think these kinds of preventable mistakes are a thing of the past. But new data from the Harvard School of Public Health, released this week, shows that's not the case. The Harvard survey indicates that one in every four Massachusetts adults has experienced a medical mistake in the past five years, or is close to someone who has. Half of these have caused serious harm. That translates to hundreds of thousands of medical injuries in a state that prides itself on having the very best medical care.
"We do a staggering amount of harm every day."Dr. Ashish Jha, Harvard
But there was also more promising medical-error news this week. Federal health officials reported a recent 17 percent reduction in “hospital-acquired conditions” such as infections, falls, trauma and bedsores. That’s 1.3 million fewer injuries and 50,000 fewer deaths since 2010, says Health and Human Services Secretary Sylvia Burwell.
“Hospitals Are Killing Tens of Thousands Fewer People” was how the Washington Post billed it – a headline that managed to sound both cheerful and not-so-reassuring.
These are big numbers, on both sides of the ledger. So what's the upshot? Do they mean American patients are safer than they were when Betsy Lehman died? Or at greater peril?
One thing’s clear: Whatever the exact numbers, they reflect a big problem that profoundly affects millions of American families.
Something like 1,000 Americans die of medical errors every day, according to one credible recent estimate. “We do a staggering amount of harm every day,” Dr. Ashish Jha of the Harvard School of Public Health testified last July at a U.S. Senate subcommittee hearing. John James of Patient Safety America, an advocacy group, recently estimated that 440,000 Americans die every year from such tragic mistakes. Nonfatal errors are 10 to 20 times more common, James says, which would mean something like 8 to 10 million medical mistakes a year.
"When you talk to people, it seems everyone has a story — everyone, whether it’s themselves, a family member, a friend,” says Barbara Fain, director of the Betsy Lehman Center for Patient Safety and Medical Error Reduction, a Massachusetts state agency whose name memorializes my Globe colleague.
Twenty years after her death, many are now asking if that movement has worked. The new federal numbers signal substantial progress toward safer care. But the new Harvard study — and a number of other recent studies — suggest that Americans are just as likely to suffer from medical errors as they were when Al Knox and Betsy Lehman died.
Which picture is right?
The truth is, no one can tell you. Because the more experts look for medical injuries, the more they find. That makes it hard to measure progress; the denominator keeps changing.
“The fundamental problem is that most health care organizations don’t track the safety of their care,” Jha told the Senate hearing. “Most hospitals, even though with electronic health record systems, do not know their own rates of adverse events. They don’t know how often they harm patients.”
That helps explain why only 753 serious errors got reported in 2013 to the Massachusetts Department of Public Health — in a state where the new Harvard data suggest hundreds of thousands occur.
Virtually no one who spoke at a Boston conference on medical errors this past week, sponsored by the Betsy Lehman Center, believed the official reports reflect the actual extent of patient harm. “Clearly, it’s not capturing a large percentage of the problems,” Fain says.
"One of the problems...remains hospitals' stubborn failure to acknowledge the harm they cause."Paul Levy, former hospital CEO
“One of the problems in Massachusetts remains hospitals’ stubborn failure to acknowledge the harm they cause,” writes Paul Levy, former CEO of Beth Israel Deaconess Hospital in Boston and now a consultant and blogger on health care quality.
And if the extent of the patient harm in hospitals is largely unreported, researchers at the Betsy Lehman Center conference said, it’s even less-examined in nursing homes, clinics and doctors’ offices.
Levy says Massachusetts is “falling behind on safety and quality,” despite its prestigious medical institutions and leading authorities in the field of patient safety.
That list includes people like Dr. Donald Berwick, founder of the Institute for Health Improvement and former head of the federal Medicare and Medicaid programs; Harvard surgeon/writer Atul Gawande, who’s famous for his surgical checklists to prevent errors; Dr. Lucian Leape; James Conway of the Harvard School of Public Health.
Conway was hired by Dana-Farber Cancer Institute in 1995 after Betsy Lehman died there to reform patient-care operations. He’s widely credited with instilling a “culture of safety” at the institution, and is now a leading national authority on patient safety.
Conway says the newly reported federal results — 1.2 million fewer patient injuries, 50,000 deaths averted — represent real progress.
But progress has been slow, Conway says. The big change over the past decade has been a realization that errors usually happen because of systemic failings, not individual incompetence or negligence. And that requires thorough-going changes in big, complicated organizations.
“People have been working unbelievably hard and I think we have to acknowledge the results they’ve achieved,” Conway said in an interview. “The report from Washington celebrated those results. But the Boston meeting was acknowledging the huge gap that remains.”
Conway worries that lower error rates at some “leading-edge” hospitals might “distract us” from the need to double down on error prevention.
"I caution against anything that allows us to take our foot off the pedal."Jim Conway, Harvard
“I caution against anything that allows us to take our foot off the pedal,” Conway says. “When I go from hospital to hospital, I still see exceptional variation.”
Many in the field think further progress won’t happen until patients and their families begin to speak up and demand accountability.
The new Harvard poll found that about half those who said they or someone close to them suffered a medical error reported it to someone — usually at the institution where it happened. Of those who didn’t report it, the great majority said they didn’t think it would do any good and many said they didn’t know how to report it.
“We have to figure out what we want the individual patient to do,” says Robert Blendon, who led the Harvard survey. “What will happen? What should they expect a hospital to do?”
Readers, what's your response to Blendon's question? What do you think hospitals and patients can be expected to do?