From: sbharris@ix.netcom.com (Steve Harris  sbharris@ROMAN9.netcom.com)
Newsgroups: sci.med
Subject: Re: 132,000 U.S. women dying each year from iatrogenic infectious 
	diseases...
Date: 13 Jun 2004 15:40:56 -0700
Message-ID: <79cf0a8.0406131440.66349325@posting.google.com>

willlocksley@aol.com (yelxol) wrote in message
news:<a71be19b.0406111033.585adf2f@posting.google.com>...

> From the book, "Fatal Probe".
> Available from Amazon.com, Barnes & Noble, and other book stores.
>
> CHAPTER IX
>
> UNREGULATED PRIVATE PHYSICIANS: A MAJOR PROBLEM FOR WOMEN
>
> In an average year in the U.S. there are 110 million gynecological
> examinations in the offices of totally *unregulated* private
> practitioners and clinics. At least 3.3 million of the women examined
> are contracting infectious/contagious diseases.
>
>   "...these iatrogenic infectious diseases are the
>    direct cause of the deaths of 132,000 U.S. women?
>    every year."
>
> The Institute of Medicine estimates that over 100,000 patients die
> every year in *highly regulated* U.S. hospitals as a result of medical
> errors or mistakes?. and beginning in 1999 that dialogue was sold to
> the American public in newspaper banners and on TV news programs
> across the nation.


COMMENT:

Yes, and immediately following that, the story that has had trouble
getting out (even though discussed here on this newsgroup ad nauseam)
is that the study which made the assertion was completely flawed. It
had no control group. The way you tell how many critically ill people
in a hospital die from medical errors, is to get such a group subject
to an error, and compare them to a group of similar patients who had
no error, and see how many EXTRA deaths there were in the error group.
You could reasonably then attribute these extra deaths to the errors.
But that's not what the quoted study did. Instead, it took a group of
very ill hospitalized patients who suffered a medical error, and
attributed ALL deaths in this group TO the error. Which is the same as
assuming that in the ABSENCE of medical errors, that very ill people
in the hospital are functionally immortal. Which is to say, that if no
mistake is made by their doctors, they cannot die. Perhaps some
malpractice lawyers would like the public to think that this is indeed
true, but I hope nobody reading this is foolish enough to think it is.

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 spend some time thereafter
whenever we could, reminding 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.sox@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]



Eff 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.
thofer@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]