Ten years ago, a highly publicized federal report entitled “To Err Is Human”, estimated that as many as 98,000 people die, each year, from preventable medical mistakes. The report called the medical error death statistic “shocking”. It issued a challenge to the U.S. hospitals, clinics and doctors to cut deaths caused by medical mistakes and neglect by one-half within five years. Ten years later, comes this national investigation by several Hearst newspapers which has determined that efforts to take steps outlined in the report to reduce deaths have fallen woefully below that which any reasonable person would consider “adequate”. Further, a separate study for the Center for Disease Control and Prevention has concluded that 99,000 patients per year die from infections acquired in the hospital. Experts have concluded that most of these deaths are also preventable. Thus, there have been no definitive studies, but if one combines these two, the conclusion is that almost 200,000 U.S. patients per year die from preventable medical injuries and conditions.
Instead of cutting these incidents in half as the “To Err” report challenges, industry analysts believe that medical mistakes are increasing, not declining. The Hearst Newspaper investigation concludes that most states, the feds, and medical and hospital communities have failed or refused to take steps outlined in “To Err” that would have reduced the number of fatal mistakes. And, in states where regulations were implemented, those rules and regulations have been ignored. As a result, the Hearst article suggests that almost 2 million people have died, needlessly, since the “To Err” report and challenge was issued.
Hearst Newspapers currently serve five states: New York, California, Texas, Washington, and Connecticut. In those states, a mere 20% of the almost 1500 hospitals surveyed are participating in recently implemented national safety campaigns. The newspaper’s investigation found major deficiencies in patient data, but still found that at least 16 percent of the hospitals examined had at least one death from a common, easily survivable procedure; some had more than 12. Simply implementing test-tube color-coding procedures would have saved lives, in some instances.
Instead of placing blame on individual doctors or nurses, the intent of the 1999 report was an acknowledgment that individuals make mistakes and a suggestion that hospitals could design systems that reduce them and/or their impact on patients. A nationwide medical mistake reporting network also failed to materialize because of an overt lack of cooperation from the medical community. Instead, the community spent $81 million in lobbying efforts and millions more in advertising to squash a 2000 patient safety agenda proposed by then President Bill Clinton.
The article contrasts the very public information available for other types of accidental death. Auto accidents, falls, poisoning, and firearm deaths all are subject to public reporting and yearly statistics are posted for all Americans to see. It opines that improved tracking of medical errors would result in its placement at the top of this list; “a visit to your doctor or a hospital is twice as likely to result in your death as is a drive on America’s highways.”
The article goes on to list key recommendations from the report and places them in the context of what action has been taken in the 10 years since the report was issued and the recommendations made. Quoting from the article:
• • Encouraged states to require medical error reporting. Only 20 states plus the District of Columbia have done so, and evidence shows that even in those mandatory-reporting states, hospitals report only a tiny percentage of their mistakes.
• • Said the public “has the right to be informed about unsafe conditions.” But 45 states plus the District of Columbia don’t provide hospital-specific information, either because they don’t allow access or because they don’t collect the data.
• • Recommended the creation of a national patient safety center. The center is underfunded and has fallen far short of expectations.
• • Urged that hospitals improve the level of safety within their walls. Hundreds of hospitals responded, a few of them comprehensively pursuing safer care. Thousands did much less.
• • Advocated a voluntary system for hospitals to report and learn from errors. Five years later, Congress approved legislation for “patient safety organizations” to serve this role, then took four more years to create rules to govern them. But the new organizations are devoid of meaningful oversight and further exclude the public.
According to U.S. Health and human Services Secretary, Kathleen Sebelius, there has not been a “significant improvement in the level of medical errors” and hospital-based preventable infections “is getting worse”. She opines that the death toll is the same as it was 10 years ago. Part of the difficulty is that death occurs behind the closed door of a clinic or hospital operating room. What really went on in there? Secrecy abounds. According to the Hearst investigation, information is changed or left off death certificates:
Medical error [in death certificates] is “often not reported,” said Robert N. Anderson, chief of the CDC’s Mortality Statistics Branch.
He said doctors aren’t given enough motivation to report medical errors, and because of liability, “it would cause them problems down the road, so that there is a disincentive to report it.”
With no federal reporting required, the issue is left to the states. Currently, 20 states and the District of Columbia have mandatory reporting systems. Five more are planning to implements systems. Of the 20 in place, only 5 (Washington, Massachusetts, Minnesota, Colorado and Indiana) have systems that reveal hospital names to consumers. Other states create a hodgepodge of inadequacy from low (or no) enforcement, to low (or no) project funding. New York and Texas, for instance, have no money or staff. The last reports from these two states were 2005 for New York and 2007 for Texas with no fund allocation in sight.
The article suggests that more secrecy can be expected and mistakes will continue. Any improvement will be too late for deceased patients like Richard Flagg and Stanley Stinnett.
In Flagg’s case, surgeons accidentally removed the 60 year old man’s healthy lung, leaving him with one diseased lung they were supposed to remove. Three years later, a tumor ruptured and he drowned in his own blood. In Stinnett’ case, the 49 year old was seen in the emergency room with broken ribs from a motorcycle accident and died as the result of a series of preventable medical mistakes.
As part of the national debate over health care and insurance, President Obama and Congress need to address the issue of hospital and clinic safety. Our United States also need to stop enacting legislation (either state or federal) that places caps on medical neglect litigation; this pro-insurance, anti-consumer legislation penalizes the unfortunate patient and provides a free pass to the offending doctors/clinics/hospitals and their insurance companies. The largest deterrent to medical neglect or mistake in the threat of a lawsuit. Secrecy policies in dealing with medical errors, coupled with the powerful pro-insurance lobby have prevented any meaningful change in the situation.
Lawsuit Financial supports national legislation to improve hospital safety, increase transparency, and mandate reporting. This unique legal finance company is one of few companies with the expertise to evaluate medical, hospital or nursing home neglect cases and provide medical malpractice lawsuit funding for these difficult, hard fought cases. For a free analysis of your legal funding situation, please call us, toll free, at 877-377-SUIT (7848) or visit our website at www.lawsuitfinancial.com.