How Many Are Dying
Unnecessarily in Health Care?
A brief summary followed by more.
The medical profession persists in saying that 100,000 patients each year die unnecessarily in medicine. That is rounding off Lucian Leape's original IOM study, based on relatively few records from 1984, that found that as many as 98,000 patients are killed unnecessarily each year in hospitals. Leape himself has said (at this link on Propublica's site) that he and the members of the Institute of Medicine knew at the time that their estimate was low. "It was based on a rather crude method compared to what we do now."
In 1994 Leape published an article in JAMA that said 180,000 in hospitals. In 1997 he raised his estimates again, but medicine continues to quote the smaller number, tellingly saying "in medicine" rather than "in hospitals" as though the number ever referred to all health care settings. It never did. It refers only to patients in hospitals which account for only about 25% of care.
“All men make mistakes, but a good man yields when he knows his course is wrong, and repairs the evil.” — Sophocles, Antigone
In 2010 the Office of Inspector General for the U.S. Department of Health and Human Services said 180,000 Medicare recipients alone die each year from mistakes in hospitals alone (at this link on their site). Medicare recipients make up only a portion of the hospital patient population. So the numbers for all patients just in hospitals is higher than that, and the number for all patients in all care setting is even higher.
The CDC says that 75,000 per year die in hospitals from infections alone - just one cause and just in hospitals.
Consider C Diff, which is only one type of infection. 75% of cases of C Diff are contracted in health care settings other than hospitals. If that percentage is consistent for other infections caught in hospitals, then infections alone may be killing 300,000 patients annually when including care settings other than hospitals. And that's just infections. There are lots of other causes.
Like fatalities caused by adverse drug reactions. According to JAMA (1998; 279(15):1200-05) the number of hospitalized patients who had fatal adverse drug reactions in a year was 106,000. That's just in hospitals. And just one more of the ways that patients are caused to die as a result of seeking care (for instance at this link the Wall Street Journal says that more patients than that die in hospitals from blood clots).
We are just getting started (lower on this page is more) and the numbers are sky rocketing past the 100,000 that medicine keeps repeating as though it were total fatalities per year in all of medicine. That is a very good picture of how strongly the prejudices of the caregiving community distort their perceptions in self-interested ways.
"If we believe absurdities, we shall commit atrocities." - Voltaire
This is nothing new. Remember those two maternity clinics in Vienna in the 1840s under the direction of Ignaz Semmelweis, one of which had a death rate of 30% some months and the other of which had a rate of 5%? Knowing those death rates did not stop physicians from sending pregnant women to both of them in equal numbers. They still do that today. The only difference is that today they do not know the differences in death rates or any other rates with a vision any clearer than the one they bring to total death rates. They do not know what and where the dangers are.
Leape, Classen and Makary all say it's time to stop citing the 98,000 number, but medicine clings to it.
All of the hundreds of thousands of people who die unnecessarily in medicine are guided to those deaths by physicians apparently in denial of the extent to which this even is a problem. That denial makes those doctors unworthy guides as to when treatment is worth the risk in the first place. How the patient community can get better guidance is what this site is about.
More on studies of the numbers of preventable deaths occurring in medicine each year are lower on this page. Clicking Next takes you, instead, to the next page it might be worth glancing at to understand the solutions proposed on this site.
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Annals of Internal Medicine found additional information
A study in the Annals of Internal Medicine** examined information that previous studies did not. They recognized the problem with basing studies only on the few adverse events health care professionals report and looked for where they could get unrecorded information (covered in more detail near the bottom of this page). They concluded that 320,000 patients die unnecessarily in medicine in the USA each year. 320,000 is more Americans than died during the entire 8 years of World War II, our deadliest war.
Leape updated his 1994 statistics saying that as of 1997 medical errors in inpatient hospital settings nationwide could be as high as 3 million and could cost as much as $200 billion. Leape used a 14% fatality rate to determine a medical error death rate of 180,000 in 1994. In 1997, using Leape's base number of 3 million errors, the annual death rate could be as high as 420,000 for hospital inpatients alone.
Concurring with Leape's estimate is A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care by John T. James, PhD in the July 2013 edition of the Journal of Patient Safety. Dr. James, who works with the space program assessing such risks, concurs with Leap's updated figures and estimates 400,000 unnecessary deaths annually in hospitals alone.
James said that serious harm appeared to be 10 to 20 times more prevelant than lethal harm, which means that between 4 million and 8 million people were seriously harmed. Beyond them is an even larger pool of patients who were injured, but not seriously.
How is it that all of this remains so invisible to our caregivers that they manage to believe that things have improved so much?
30,000 per month
Death By Medicine, by Gary Null, puts the figures at around 1 million patients dying unnecessarily per year. He is not the only one arriving at such a figure, but on this site I use the figure from Leape and others rounded down to an even 30,000 per month for the purposes of discussion.
The CDC reports that 1.7 million patients are infected during the course of treatment in hospitals each year (at this link on their site) and that 99,000 of them die (a number that fluctuates year to year). Hundreds of thousands of the ones who do not die never will be the same.
The accident pyramid (at this link on this site) suggests that if 99,000 die, the number infected is millions more than the CDC has been able to determine. Medicine is so good at covering up problems that even the number thought to die most likely is an underestimate. For instance, in another study by the CDC 70% of physician respondents said that they were forced to report an alternate cause of death when the patient died of septic shock, the leading cause of death in ICUs (footnoted here). Which means they were not counted as patients who died from infections caught in hospitals.
The number of patients dying from hospital acquired infections can be, and elsewhere has been brought nearly to zero (for instance, this link on another site). Elsewhere on this site is discussion about why our health care professionals do not want to do that (at least not enough to do it) and what could be done about that (for instance, see Semmelweis).
For a more narrow focus to help understand the subject, the CDC estimates that for one specific kind of procedure, central-line catheters, infections are caused in 250,000 patients annually, costing $25,000 each and claiming the lives of one in four of those infected patients. Focusing on this one single procedure could bring that number to zero.
IOM studied only 30,000 records
from the year 1984
The oldest study is the one from which health care keeps quoting numbers that long have been antiquated. So journalists tend to quote them too. They are from the 1999 Institute of Medicine (IOM) report "To Err is Human" by Lucian Leape, that concluded that between 48,000 and 98,000 patients die each year as a result of preventable medical errors committed in hospitals, but that was based only on data that was reported by health care professionals who don't report most adverse events (see Medical Reporting) and only on data from three states long ago when there were fewer admissions to hospitals.*
HealthGrades studied 37,000,000 records
from 2000 to 2002
That is 1,000 times as many records as the original IOM study. HealthGrades, the health care quality company, looked at 37 million patient records taken from three years of Medicare data in all 50 states and D.C., approximately 45 percent of all hospital admissions (excluding obstetric patients) in the U.S. from 2000 to 2002. They found that an average of 195,000 patients in the USA died in each of those years due to potentially preventable, in-hospital medical errors. But, once again, they were working only with data that had been reported by health care professionals, and health care professionals report only 2% of adverse events accurately (see Medical-Reporting).
Annals of Internal Medicine found additional information
A study in the Annals of Internal Medicine** examined information that previous studies did not. They recognized the problem with basing studies only on the few adverse events health care professionals report and looked for where they could get unrecorded information. They conclude that 320,000 patients die unnecessarily in medicine in the USA each year. Their report, written by 10 experts with various advanced degrees (including three MDs) in the July 15, 2008 issue, sought to discover if patients' knowledge of medical errors revealed errors that the medical records did not. In the Annals study, serious preventable patient harm problems documented in medical records of 1,000 patients hospitalized in 2003 in Massachusetts were compared with serious preventable patient harm problems that patients themselves could recall 6-12 months after their discharge.
Only eleven serious preventable problems for patient harm were documented in the medical records created by caregivers, but patients reported 21 additional ones that were confirmed (by an investigating team) that the healthcare professionals did not report. If the rate of documentation of serious preventable patient harm problems in medical records is the same as the rate of documentation of lethal medical problems for patient harm in the records used by the Harvard study, a better estimate of lethal medical events would be 110,000 x (21 + 11)/11 = 320,000 unnecessary deaths per year. That is approaching a thousand per day. And this estimate is based only on the cases that could be confirmed.
In an environment in which only 2% of adverse events get reported (see Medical Reporting) accurately by health care professionals, and an unknown number of events reported by patients could not be confirmed, how much larger might the fatality figure be if either health care professionals reported honestly or more of the events reported by patients could be confirmed? The routine expertness and ubiquity with which medicine erases evidence, and memory, of adverse events makes confirming anything a rarity (ask injured patients).
CDC & Infections
The Centers for Disease Control (CDC) determined that 99,000 patients die each year from one single source alone - infections caught unnecessarily in hospitals. There are additional sources of unnecessary death in medicine. And hospitals are not the only place in medicine where patients die unnecessarily. For instance, most infections resulting in death are caught in healthcare settings other than hospitals. Considering just one infectious disease, C. difficile, 75% of fatalities contract the infection in nursing homes, primary care physicians' offices, and similar non-hospital settings. The 99,000 number counts only people who died as a result of only one problem, infections, and only those caught in one kind of healthcare facility, hospitals.
According to an article in the Wall Street Journal, one other problem in hospitals kills about 200,000 patients annually - blood clots. Deep-vein thrombosis (DVT) or venous thromboembolism events (VTE) can hit any bedridden patient after surgery. Mostly it is people over 40 years old who die from it. However, it is the leading cause of maternal death after childbirth.
*The original Institute of Medicine study was based on
physician examination of the medical records of 30,000 patients receiving
care in New York hospitals in 1984. Of the 30,000 patients studied by the
Harvard group, 87 died as a result of preventable medical errors committed
while they were hospitalized. These data, when extrapolated to all
admissions in U.S. hospitals in 1997, yield 98,000 preventable deaths
nationwide in 1997 when there were 34.6 million admissions. But each year
the number of admissions increases. In 2002 there were 37.8 million hospital
admissions. For that year the estimated total is 110,000 preventable deaths
per year based on evidence in medical records alone.
But, as this site continually points out, people in medicine do not record most of what should be put in the record. Where else to get the information? From patients.
**From an article called "Comparing Patient-Reported
Hospital Adverse Events with Medical Record Review: Do Patients Know
Something That Hospitals Do Not?"
by Joel S. Weissman, PhD; Eric C. Schneider, MD, MSc; Saul N. Weingart, MD, PhD; Arnold M. Epstein, MD, MA; JoAnn David-Kasdan, RN, MS; Sandra Feibelmann, MPH; Catherine L. Annas, JD; Nancy Ridley, MS; Leslie Kirle, MPH; and Constantine Gatsonis, PhD
in The Annals of Internal Medicine, 15 July 2008 | Volume 149 Issue 2 | Pages 100-108
The abstract is viewable at: http://www.annals.org/cgi/content/abstract/149/2/100
*** Accident pyramid or Safety pyramid
In 1931, H.W. Heinrich theorized that for every major accident there are 29 minor accidents and 300 near misses. This theory has been reevaluated several times, including by Conoco Phillips in 2003, where it was determined that for every fatality there are 30 lost day injuries, 300 recordable injuries, 3,000 near misses, and 300,000 unsafe acts.
In many cases when someone dies as the result of an infection acquired in a hospital, the infection is not listed on the death certificate as the cause of death. They don't even admit the wrong let alone repair it.