Physicians divided: Report of medical-error deaths on target or exaggerated?

July 5, 2000
Web posted at: 9:18 a.m. EDT (1318 GMT)

In this story: Dispute over methodology 'Shocking figures' RELATED STORIES, SITES

From staff and wire reports

ATLANTA (CNN) -- The Journal of the American Medical Association this week contains conflicting evaluations of a widely noted report that as many as 98,000 people die each year from medical errors in American hospitals.

The Institute of Medicine (IOM) last November claimed more people die in American hospitals from medical mistakes than die nationwide from better known causes including highway accidents, breast cancer or AIDS.

The report prompted U.S. President Bill Clinton to order a study of preventable deaths in federal health care facilities. Congressional hearings were initiated.

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But this week, Dr. Clement McDonald and two colleagues, all of the Indiana University Center for Aging Research, argued that the reported number of deaths in the IOM study was exaggerated.

In a defense of the IOM report, Dr. Lucian Leape of the Harvard School of Public Health disputed that charge, saying the death figures were more likely underestimated. Leape is a coauthor of the challenged study.

The Institute of Medicine report said mistakes in administering medicines and other errors by doctors and nurses cause between 44,000 and 98,000 deaths in hospitals each year.

The national figures came from statistical extrapolations of studies in New York, Colorado and Utah. Death rates attributed to medical errors in those studies were applied to a much larger number of patients admitted to hospitals throughout the country.

McDonald criticized the manner of selecting patients whose records were included in the studies by Leape and others. The selected patients, he argued, were already very sick, and the lack of any comparison group made the study flawed.

"Most patients admitted to hospitals have high disease burdens and high death risks even before they enter the hospital," wrote McDonald. "Although some hospital deaths are preventable, most will occur no matter how many 'accidents' we avoid."

He added that medical errors "are never excusable, but the baseline death risk has be to be known and factored out before drawing conclusions about the real effect of adverse reactions on death rates, preventable or otherwise."

In his rebuttal, however, Leape said most patients in the study probably would not have died if an error had not been committed.

To identify patients whose deaths in hospitals appeared related only to mistakes by doctors and nurses, Leape said, terminally ill and severely ill patients and those with complicated health problems were excluded.

"All patients who had major surgery, acute myocardial infarction (loss of some heart-muscle use), pneumonia or stroke who had an uncomplicated course … were excluded," he said. The goal was to study relatively low-risk patients who would almost certainly have left their hospitals alive but who died.

Leape went on to say that the death figures, though "shocking," were probably too low, because some factors were not considered.

The studies did not include deaths from medical errors that occured outside a hospital setting, such as in outaptient surgical centers, nor could they take into account medical errors that were not recognized or not reported, he wrote.

Clinton administration officials are working toward establishing a confidential means for hospital staff members and others to report serious medical errors to a central office -- without regard to any individual’s culpability.

Leape applauded the effort. Most errors, he wrote, are due to "defects in the design and conditions of medical work," not personal carelessness.

"Rather than attempting to assuage guilt or outrage about errors by punishing, discounting or self-flagellation, physicians need to look to preventing recurrence of errors."

The objective, set forth in the November account, is to emphasize identification of common mistakes, then to educate doctors and nurses nationwide in how to avoid them.

McDonald argued that before any policies are implemented, a more thorough study of the death rates caused by medical errors needs to be done, to determine the true extent of the problem.

Reuters contributed to this report.

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