COMMENT:

Repeating it won't make it so. THERE WAS NO CONTROL GROUP. And without
one, you cannot TELL who died OF the medical error (usually).  All you
can tell is that they died AFTER it, and take your best GUESS as to
whether or not this very ill person would have made it, if the error
had not occurred. I've appended a number of abstracts pointing out all
this out, and even one in which the doctors actually tried to do a best
guess as to whether or not error made in hospitals were indeed fatal,
using the baseline that the patient would otherwise would be expected
to have left the hospital and lived another three months.

Remember, please, that as patients who are dying of cancer or old age
or some chronic disease become more and more frail, they become more
and more like a house of cards with too many cards. It becomes more and
more difficult to do ANYTHING for them without small imperfections in
your technique causing possibly major problems. Or to put it another
way, getting them to live through any interventive procedure takes
greater and greater skill until finally you hit the wall where only the
best surgeon or intensivist on the planet *might* be able to get them
through the next infection or stint on the ventilator or surgical
procedure (which they need to survive another couple of weeks) but that
person isn't available. That's *how* people often die if you have no
hospice and nobody is willing to "give up."  Sorry.  And you can always
witchhunt and find somebody to blame. Indeed, if the doctors refuse to
do anything, knowing that doing anything will probably be useless
and/or carry a high degree of causing yet more problems, you can always
fire them and find a doctor who's willing to try it anyway. Or you can
sue everybody for failure to provide care.

Here's a patient whose heart probably isn't up to the extra load of
hemodialysis. But their kidneys aren't working. The last time they were
dialyzed they nearly died, but didn't because the technician happened
to know the latest tricks of keeping the blood pressure just right with
the latest machine. But *that* guy's on vacation. So now what? If you
don't dialyze, the patient will surely die. If you do, the next tech
will probably kill them. But maybe not. There you go.

Whatever you do, you're betting a small chance of extending life,
against an extra risk of dying NOW if you operate, or whatever (vs
doing nothing, in which case the patient will surely die during the
hospitalization, but maybe not this second). And if the operation or
procedure or drug kills them, or some problem while delivering it
pushes them over, you can always say they were ROBBED of a few days or
hours or seconds of life.

COMMENT:

FROM A MESSAGE POSTED A YEAR AGO (this seems to come up once a year,
while all the doctor bashers are on on vaccation):

S.B.Harris, M.D.

Here is a sad truth of physiology that every physician knows: in any
developed country, most deaths happen in the aged and the otherwise
very infirm, frail, and chronically ill. Such people, as they approach
the day of their deaths, become more and more like a house of cards
which is waiting for that last card of that last puff of wind.
Sometimes what sends them over is a medical error. Often enough, it's
the kind of error that all but the terminally ill would survive. If no
error is made, it's always something else.

Let me pause for an illustrative story. When I was a resident we had
an elderly respiratory patient who always pestered the staff about her
diet. Because she had no dentures, she had been ordered a pureed diet.
That was fine with her, but she couldn't get her favorite food, which
was a boiled egg for breakfast. Each day she demanded a boiled egg,
which the dietary service could not provide on the diet orders she had
writen. Until finally the nurses started calling the housestaff about
it. It was thought that a mechanical soft diet in general would be too
much for the woman, but perhaps an egg could be excepted. So one of my
interns, desiring to increase the quality of the woman's life and to
cut short the infernal complaining, literally wrote the following
medical order on the woman's chart: "Please give pt [patient] boiled
eggs PRN [meaning whenever she likes]."

This was early in the morning. Later in the morning there was a "code"
(an arrested patient) and the code team found that the arrested
patient was the boiled egg lady. The next orders in the chart to be
writen after "Please give pt boiled eggs PRN" were the code medication
orders. And these were the last orders also, because the women did not
survive. The code intern found difficulty intubating the woman through
the remains of boiled egg in her trachea, which she had aspirated.

With the cruel humor of all housestaffs, we spent some time thereafter
whenever we could, remaining the unfortunate intern about how he had
killed the "boiled egg lady" with his boiled egg order.  Surely a fatal

medical error.

And now, for some hardboiled abstracts on the subject. Pay attention
particularly to the last one:

==============================­=========
Eff Clin Pract.  2000 Nov-Dec;3(6):277-83.

How many deaths are due to medical error? Getting the number right.
Sox Jr HC, Woloshin S.

Dartmouth Medical School, Hanover, NH, USA. harold.c....@dartmouth.edu

CONTEXT: The Institute of Medicine (IOM) report on medical errors
created an intense public response by stating that between 44,000 and
98,000 hospitalized Americans die each year as a result of preventable
medical errors. OBJECTIVE: To determine how well the IOM committee
documented its estimates and how valid they were. METHODS: We reviewed
the studies cited in the IOM committee's report and related published
articles. RESULTS: The two studies cited by the IOM committee
substantiate its statement that adverse events occur in 2.9% to 3.7% of
hospital admissions. Supporting data for the assertion that about half
of these adverse events are preventable are less clear. In fact, the
original studies
cited did not define preventable adverse events, and the reliability of
subjective judgments about preventability was not formally assessed.
The committee's estimate of the number of preventable deaths due to
medical errors is least substantiated. The methods used to estimate the
upper bound of the estimate (98,000 preventable deaths) were highly
subjective, and their reliability and reproducibility are unknown, as
are the methods used to estimate the lower bound (44,000 deaths).
CONCLUSION: Using the published literature, we could not confirm the
Institute of Medicine's reported number of deaths due to medical
errors. Due to the potential impact of this number on policy, it is
unfortunate that the IOM's estimate is not well substantiated.
Publication Types:
   Review
   Review, Tutorial
PMID: 11151524 [PubMed - indexed for MEDLINE]

Hosp Case Manag.  2000 Oct;8(10):suppl 3-4, 146.
University study identifies problems with IOM report.
[No authors listed]

The Institute of Medicine's (IOM) report on medical errors is faulty
because it does not include a control group and all the patients
studied were 'very sick' according to researchers at Indiana
University. "What the figures suggest is that people don't die [without
an adverse event]," says Clement J. McDonald, MD, director of the
Regenstrief Institute and Distinguished Professor of Medicine at
Indiana University School of Medicine in Indianapolis. McDonald is
referring to the study released by the IOM of the National Academies in
November that states 'preventable adverse events are a leading cause of
death' and 'at least 44,000 and perhaps as many as 98,000 Americans die
in hospitals each year as a result of medical errors.
PMID: 11143166 [PubMed - indexed for MEDLINE]

=====================ïf Clin Pract.  2000 Nov-Dec;3(6):261-9.

Comment in:
   Eff Clin Pract. 2001 May-Jun;4(3):141; author reply 142.
   Eff Clin Pract. 2001 May-Jun;4(3):141; author reply 142.

What is an error?
Hofer TP, Kerr EA, Hayward RA.

Department of Veterans Affairs, VA Center for Practice Management and
Outcomes Research, VA Ann Arbor Healthcare System, Ann Arbor, Mich.,
USA.
tho...@umich.edu

CONTEXT: Launched by the Institute of Medicine's report, "To Err is
Human," the reduction of medical errors has become a top agenda item
for virtually every part of the U.S. health care system. OBJECTIVE: To
identify existing definitions of error, to determine the major issues
in measuring errors, and to present recommendations for how best to
proceed. DATA SOURCE: Medical literature on errors as well as the
sociology and industrial psychology literature cited therein. RESULTS:
We have four principal observations. First, errors have been defined in
terms of failed processes without any link to subsequent harm. Second,
only a few studies have actually measured errors, and these have not
described the reliability of the measurement. Third, no studies
directly examine the relationship between errors and adverse events.
Fourth, the value of pursuing latent system errors (a concept
pertaining to small, often trivial structure and process problems that
interact in complex ways to produce catastrophe) using case studies or
root cause analysis has not been demonstrated in either the medical or
nonmedical literature. CONCLUSION: Medical
error should  be defined in terms of failed processes that are clearly
linked to adverse outcomes. Efforts to reduce errors should be
proportional to their impact on outcomes (preventable morbidity,
mortality, and patient satisfaction) and the cost of preventing them.
The error and the quality movements are analogous and require the same
rigorous epidemiologic approach to establish which relationships are
causal.
Publication Types:
   Review
   Review, Tutorial
PMID: 11151522 [PubMed - indexed for MEDLINE]

JAMA.  2001 Jul 25;286(4):415-20.
Comment in:
   JAMA. 2001 Dec 12;286(22):2813-4.
Estimating hospital deaths due to medical errors: preventability is in
the eye of the reviewer.
Hayward RA, Hofer TP.

CONTEXT: Studies using physician implicit review have suggested that
the number of deaths due to medical errors in US hospitals is extremely
high. However, some have questioned the validity of these estimates.
OBJECTIVE: To examine the reliability of reviewer ratings of medical
error and the implications of a death described as "preventable by
better care" in terms of the probability of immediate and short-term
survival if care had been optimal. DESIGN: Retrospective implicit
review of medical records from 1995-1996. SETTING AND PARTICIPANTS:
Fourteen board-certified, trained internists used a previously tested
structured implicit review instrument to conduct 383 reviews of 111
hospital deaths at 7 Department of Veterans Affairs medical centers,
oversampling for markers previously found to be associated with high
rates of preventable deaths. Patients considered terminally ill who
received comfort care only were excluded. MAIN OUTCOME MEASURES:
Reviewer estimates of
whether deaths could have been prevented by optimal care (rated on a
5-point scale) and of the probability that patients would have lived to
discharge or for 3 months or more if care had been optimal (rated from
0%-100%). RESULTS: Similar to previous studies, almost a quarter
(22.7%) of active-care patient deaths were rated as at least possibly
preventable by optimal care, with 6.0% rated as probably or definitely
preventable. Interrater reliability for these ratings was also similar
to previous studies (0.34 for 2 reviewers). The reviewers' estimates of
the percentage of patients who would have left the hospital alive had
optimal care been provided was 6.0% (95% confidence interval [CI],
3.4%-8.6%).However, after considering 3-month prognosis and adjusting
for the variability  and skewness of reviewers' ratings, clinicians
estimated that only 0.5% (95% CI, 0.3%-0.7%) of patients who died would
have lived 3 months or more in good cognitive health if care had been
optimal, representing roughly 1 patient per 10 000 admissions to the
study hospitals. CONCLUSIONS: Medical errors are a major concern
regardless of patients' life expectancies, but our study suggests that
previous interpretations of medical error statistics are probably
misleading. Our data place the estimates of preventable deaths in
context, pointing out the limitations of this means of identifying
medical errors and assessing their potential implications for patient
outcomes.

PMID: 11466119 [PubMed - indexed for MEDLINE]