Op-Ed Column: Medical Mistakes Plague Medicare Patients

By Daniel R. Levinson
Inspector General, US Department of Health and Human Services

Today's hospitals are modern-day marvels of healing, and we expect them to be models of patient safety as well. But a just-released report from my office shows that medical care is falling short for too many hospitalized Medicare patients. A decade after an Institute of Medicine study placed preventable medical errors among the leading causes of death in the United States, our latest study found that a disturbing number of hospitalized patients still endure harmful consequences from medical care, 44% of them preventable. These instances, which the report calls "adverse events," include infections, surgical complications and medication errors.

Such occurrences are not always preventable, particularly since many Medicare patients are elderly and have complicated health problems. But enough patient harm is avoidable to make a strong case for action. Hospitals must improve, but they need the help of lawmakers, medical professionals and patients to do so.

Errors prolonged hospital stays

This study began in response to a congressional mandate to determine the number of harmful medical events Medicare patients experienced, and the cost to taxpayers. My office arranged for physician reviewers to examine a random sample of 780 Medicare patients discharged from hospitals around the country during the month of October 2008.

Physicians determined that about one in seven patients (13.5%) experienced at least one serious instance of harm from medical care that prolonged their hospital stay, caused permanent harm, required life-sustaining intervention, or contributed to their deaths.

Projected to the entire Medicare population, this rate means an estimated 134,000 hospitalized Medicare beneficiaries experienced harm from medical care in one month, with the event contributing to death for 1.5%, or approximately 15,000 patients.

Strikingly, medication errors factored in more than half the patient fatalities in our sample, including use of the wrong drug, giving the wrong dosage, or inadequately treating known side effects. Such events were commonly caused by hospital staff diagnosing patients incorrectly or failing to closely monitor their conditions.

Less serious harm also occurred. An additional one in seven hospitalized Medicare patients experienced temporary problems, such as allergic reactions or injuries from falls. And many

experienced multiple events, including an elderly heart patient who had six separate events during a single hospital stay. Obviously, this situation is unacceptable - and expensive, costing taxpayers more than $4 billion a year due to the need for additional treatment or longer hospitalizations (and even more if you add costs for follow-up care).

Hospitals clearly want to excel in patient care - and often do. Still, improvements can and must take place. Fully addressing the far-reaching implications of our study requires both an official response and a personal one.

The report made recommendations for improvement to agencies within the Department of Health and Human Services that monitor medical care. Those agencies are committed to increasing medical effectiveness and have embraced the recommendations. Among them are the following:

• Too many patient safety efforts concentrate on a narrow list of egregious medical problems that thankfully occur rarely, such as surgery performed on the wrong body part. This focus overlooks the need to also concentrate on far more common harmful incidents, such as blood clots and poor diabetes control.
• Government, which pays for a large portion of the nation's medical care, must hold hospitals accountable for better care. New authorities granted by Congress further enable the Medicare program to use hospital performance as a basis for payment. Private insurers can join Medicare in finding effective ways to tie payment to quality.

Government commitment is important, yet hospitals bear much of the responsibility. Although hospitals have broadly embraced safety initiatives, the still-high rate of adverse events indicates that far more needs to be done. Hospitals must work faster to adopt evidence-based practices that reduce medical errors. Hospitals can also learn together by volunteering to join patient safety organizations, which collect confidential information about instances of harm that occur from medical care to assess what went wrong and improve patient safety. Further, hospitals can continue to improve patient care systems, including effective use of electronic health records, to help staff avoid mistakes and to alert them to problems.

What you can do

Vigilance saves lives. Family members with hospitalized loved ones should educate themselves regarding medical treatment and expected outcomes and speak up when things go awry. Hospital staff should treat patients and their families as partners, welcoming family monitoring of patients as an additional safeguard against poor medical outcomes.

Sooner or later, most of us will need the help of hospitals. They have earned their current, central place in saving lives and curing disease. We owe it to these critical institutions to help them increase quality of care for the continued health of us all.