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Report: Hospital errors cause 15,000 deaths per month

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A major federal study released yesterday suggests that state regulators aren't getting the full story from California hospitals when it comes to reporting serious lapses in care. And if the results of the nationwide probe apply here, hospitals could be withholding reports of as many as 20,000 incidents.

The federal study [PDF] found that one in seven Medicare patients are harmed while in a U.S. hospital, and 15,000 die each month as a result of lapses by hospitals and their employees.

The report by the Health and Human Services Inspector General’s Office found that 44 percent of the errors were preventable and spurred declarations of a crisis.

The report is based on the findings of a team of doctors who reviewed the records of 780 Medicare patients who were in a U.S. hospital during October of 2008. The report findings are considered reliable enough to draw conclusions about all Medicare patients who received care in a hospital.

If their conclusions hold in California, then the implications are serious.

In the fine print of the report [PDF], you can see that a tiny fraction of the medical errors are so-called "never events," [PDF] as defined by the National Quality Forum. (They're now called "serious reportable events," but I'll use the shorter designation for now.)

Those include leaving a sponge inside a patient after surgery, operating on the wrong patient and two dozen other mishaps that California now requires hospitals to report [PDF].

In the 780 cases that doctors examined, they found only five such cases, representing 0.64 percent of the total and including serious medical errors and major bedsores.

Multiply that by the million cases during the study period, and the report authors estimate that such incidents befall just over 6,300 Medicare patients in a month.

Ever curious, I wondered, if these worst-case scenarios happen in 0.64 percent of hospital stays nationwide, what do the numbers look like in California?

Here’s what I found. According to OSHPD, there were about 3.73 million hospital discharges [PDF] in California in 2008. Assuming that the rate of disasters affecting Medicare patients nationwide also applies to patients in California, you’d expect a total of 23,757 “never events,” like medication-related deaths or serious bedsores.

The report estimates that the percentage rate of 0.64 serious errors could actually be as low as 0.27 percent or as high as 1.53 percent, putting California’s expected number of errors as low as 10,000 or as high as 57,000.

Let’s compare that with the number of such events that California hospitals reported in 2008. According to the Department of Public Health, hospitals reported 1,509 such incidents in the 2008-09 fiscal year.

The state also fined hospitals that year for failing to report 153 events on time, typically nabbing hospitals when they file a report after the legal timeframe.

That leaves, by my count, roughly 20,000 incidents that may have occurred but were never reported.

Certainly, there could be problems with the study that make it risky to draw such a conclusion. For one, the inspector general only looked at cases in October, and it could be argued that doctors and nurses were particularly absent-minded that month. The study also looked at patients who were mostly 65 and older, which could be a group that is more prone than the general California population to get bedsores or experience falls and other “never events." And the fact that only 5 of the 780 cases involved "never events" could raise questions about drawing any major conclusions.

Still, as I wrote a couple weeks ago, state authorities already told Sen. Elaine Alquist, an architect of the adverse event disclosure laws, that they are pressing hospitals to disclose adverse events.

Public health officials wrote to the chief executives of 80 hospitals that never reported a single serious lapse, calling on them to report such incidents or certify that none happened.

Whether reports about 20,000 medical errors come in – that remains to be seen.

 

Comments

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elfsysop's picture
The chilling aspect of this well written and informative story is not that these facts exist, but that I sense an underlying sense of surprise by the writer. How can a bureaucracy like Medicare do anything but fail? How can a government run healthcare program, no matter how well intentioned, do anything but fail? When non-paying customers are thrust into private and public hospital businesses, over crowding and mistakes will happen. Of course these patients have all been well cared for all of their lives, right? Of course the dying Medicare patients didn't suddenly show up at the ER after neglecting their own health and welfare for years, correct? Not to place blame on the "victims" but to blame the hospital, staff, or doctors - is that fair? If the public needs to see deaths in hospitals as the result of the utter failure of government, then so be it. Be forewarned that these grim statistic are just a prelude to the massive numbers of fraud, waste, injury and death that is to come into the public light as more and more US citizens are subject to government run healthcare in all of its nefarious forms. First we will see shortages of care, then declines in quality, then increases in errors and deaths. As the system collapses and people wonder what went wrong, perhaps they will recall that whenever the government tries to do anything it was not mandated in the constitution to do, it has failed.
tafkam's picture
This was a government analysis that only looked at Medicare patients. Only a government program would even look. The private insurance companies are not looking. Do you think that errors only occur to Medicare patients? They occur, unfortunately, to everyone. At least Medicare is trying to get a handle on them and correct them. Furthermore, Medicare is not "government run health care," it is a program where the government pays doctors and hospitals, like an insurance company, but without siphoning off 30% of the take for profits, CEO salaries, shareholders dividends, and an army of clerks whose sole function is to figure out how not to pay for the health care that people like us think our premiums have entitled us to.
S. Marcus's picture
The article is mystifying. If "never events" constitute only a "tiny fraction of the medical errors", why are they the exclusive focus of this report? Confusion reigns from the very start. The opening paragraph is incomprehensible until one has read two-thirds of the article. Rewrite recommended!

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