For the last couple of days, the Twitter medical community has been discussing the latest in a long line of papers attempting to estimate the role of medical error as a cause of death. A entry appeared in the BMJ and was by a surgeon at Johns Hopkins, Dr. Martin Makary, who claims that 251,454 patients die from medical error every year. Makary’s review extrapolated that figure from three papers published before 2009 which had a combined 35 supposedly preventable deaths. That’s not a typo: 35 deaths in all. One of the papers stated that all nine deaths in three tertiary care hospitals were preventable. In his BMJ paper, Makary says, “some argue that all iatrogenic deaths are preventable.” I disagree. I have analyzed other papers on this subject and pointed out that certain complications and deaths are not 100 percent preventable. For example, no study of deep venous thrombosis and pulmonary embolism shows total efficacy of any prevention strategy. And some patients will suffer myocardial infarctions and die even when they are properly treated. In this month’s BMJ Quality and Safety, Dr. Helen Hogan of the Department of Health Service Research and Policy at the London School of Hygiene and Tropical Medicine discusses the problems associated with using preventable deaths as a measure of quality. In the UK, 40 percent of deaths occur in patients over 80 years old, and half of the people in the UK end their lives in hospitals. Hogan says, “Expected deaths as a result of underlying disease account for a large proportion of mortality, making it difficult to identify a signal of preventable deaths due to problems with care.” When errors occur, it can be difficult to decide how much they contribute to the mortality of elderly patients. Whether a death is preventable or not is often subjective and may depend upon the completeness of records and the “hindsight bias” of the reviewers. The largest retrospective case record review done in England found that only 3.6 percent of deaths were preventable. Hogan writes, “The vast majority of deaths do not involve quality problems [and] preventability of death is often difficult to determine.” Who dies in U.S. hospitals? According to the Centers for Disease Control, about 715,000 people died in hospitals in 2010. Of those who died, 75 percent were age 65 and over, and 27 percent of in-hospital deaths were in patients 85 and over. The average age of patients who died in a hospital in the first decade of this century was 72 to 73. Makary wants the CDC to start tracking medical errors. In a Forbes blog post about his paper, he said in an interview, “We need to insure legal protections so doctors can report accurately without repercussions.” I laughed out loud at that. I don’t think there is a doctor in the United States who would be stupid enough to write “medical error” on a death certificate for any patient. About 18 years ago, The Institute of Medicine “called for a culture of confession” in its first report on medical error. So far, that culture has not materialized. Makary co-authored a 2015 paper entitled “Early hospital readmission for gastrointestinal-related complications predicts long-term mortality after pancreatectomy.” Hospital readmission within 30 days for gastrointestinal complications occurred in 128 (21.5 percent) of 595 patients who underwent pancreatectomy from 2005 to 2010, and 31 (29 percent) of those patients admitted within 30 days of their surgery died. Did Makary or his colleagues write “medical error” on the death certificates of any of these 31 patients or were all of the deaths not preventable? Medical errors do occur, and they should be identified and prevented. Makary’s essay shines no new light, only heat, on the subject. Source
