\nKeywords<\/em><\/strong>: Medical error, fatal, causes of death, top ten, death, dying, end-of-life planning.
\nCitation<\/em><\/strong>: Windrum B. It\u2019s time to account for medical error in \u201ctop ten causes of death” charts. J Participat Med. 2013 Apr 24; 5:e17.
\nPublished<\/em><\/strong>: April 24, 2013.
\nCompeting Interests<\/em><\/strong>: The author has declared that no competing interests exist.<\/p>\n
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Medical error has been reliably identified as one of America\u2019s leading causes of death. The Institute of Medicine\u2019s (IOM) landmark report, To Err is Human: Building a Safer Health Care System<\/em>, concluded in 1999 that 44,000 to 98,000 annual deaths resulted from medical error. Starting in 2003, HealthGrades\u2019 Patient Safety in American Hospitals showed that about 195,000 annual deaths result from medical error. In 2010 the U.S. Department of Health and Human Services Office of Inspector General report, Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries<\/em>, found up to 180,000 deaths annually attributable to medical error.<\/p>\n I have been attuned to medical error issues ever since my parents\u2019 terminal hospitalizations in 2004 and 2005 — first my mother\u2019s, after 3 weeks of intubation in a callously-run ICU, then my father\u2019s fifteen months later for elective pacemaker eligibility testing that devolved to a fatal hospital-acquired MRSA infection. As I learned more about medical error reporting, I came to realize that despite having been repeatedly identified as among the leading causes of death in America, the presence of fatal medical error wasn\u2019t accounted for where it matters most: where and when medicine and people come together to explore end of life issues. Medical error has never been mentioned in any provider- or university-sponsored public end of life panel discussion I\u2019ve witnessed, and it never appears in those \u201ctop ten causes of death\u201d charts that pop up periodically such as the one published in the New England Journal of Medicine\u2019s<\/a> 200th anniversary issue (June 2012).<\/p>\n I\u2019m less interested in the data per se than I am in its potential utility for end-of-life planning by families with a declining or terminal loved one who need to assess risk. I think that understanding the risk of fatal medical error is more likely when it\u2019s presented in relationship to other major causes of death rather than solely as a gigantic number as in the landmark reports.<\/p>\n It\u2019s past time for medical error to appear in \u201ctop ten\u201d charts and also to acknowledge it during public end of life discussions that often are citizens\u2019 first exposure to providers offering end-of-life guidance. I\u2019m a layperson; neither a scientist, a doctor, nor a statistician, but as I understand things, medical error is underestimated and unacknowledged because:<\/p>\n How are we to know how many medical error deaths should be added independent of other categories of dying, and how many need to be included in death statistics that compound inaccurate analysis by being attributed to other causes?<\/p>\n We have to start somewhere.<\/p>\n My exposure to medical error began during Mom\u2019s terminal hospitalization. The errors were small and mundane. Items dropped on the floor put into service; an air mattress ordered for her very low internal temperature and as a bedsore prophylactic took a day to arrive — we found it under Mom but neither plugged in nor inflated (that took another 12 hours). Although these were not fatal errors they certainly didn\u2019t help a patient described to me as the most critically ill in the facility.<\/p>\n Dad\u2019s MRSA error was fatal. However, his death wasn\u2019t ensured by acquiring MRSA; that required a range of communication failures around a scheduled surgery to drain the wrist infection where the MRSA lodged, which required general anesthesia due to his previously weakened heart. We all agreed, feeling that this was not a heroic treatment choice. Dad had one stipulation: no intubation. The anesthesiologists refused it but failed to inquire what lay behind the stipulation (Dad\u2019s experience of Mom\u2019s terminal hospitalization) or to offer us any options whatsoever.<\/p>\n We hadn\u2019t gotten close enough to the time of surgery to have been presented with a surgical release form (which, I\u2019m told, would have stipulated the suspension of Dad\u2019s Do Not Resuscitate (DNR) order). Had we encountered the release form we would have asked questions and learned about typical hospital procedures suspending DNRs during surgery and for anywhere from two to forty-eight hours post-op (depending upon the facility\u2019s rules). We would have learned that post-op intubation is rarely required, and I would have advised Dad to go for the surgery. If post-op intubation were in his case, I would have had it stopped after whatever fixed timeframe Dad and the docs might have negotiated (a \u201ctime-based trial\u201d). Instead, eighteen months passed before I learned of and heard the phrase — for the first time — in a conversation with medical ethicist Diann Uustal RN, who described it as a standard clinical option whereby a treatment, if necessary at all, proceeds for no longer than an agreed-upon, fixed period of time and, if unsuccessful, is by prearrangement changed or abandoned.<\/p>\n I felt hollow upon learning about these aspects of life support and resuscitation matters so long after Dad died; all of this ought to have been introduced to us at the time. This communication failure, another type of error, led directly to Dad\u2019s death because a failure to disclose meant that options were needlessly foreclosed. So Dad died four days later in the hospice wing. My two consolations are that he, lucidly, made the decision himself; and that this snafu stimulated me to learn an enormous amount about resuscitation matters which has greatly informed my ability to act as a medical advocate or proxy when the need next arises. <\/p>\n I vowed to get to the bottom of all the failures, medicine\u2019s and our own, and to share my findings. I wrote a book (Notes from the Waiting Room: Managing a Loved One\u2019s (End of Life) Hospitalization<\/em>) which has helped hundreds of people gain insight into advocating medically and re-visioning end of life in order to actualize our universal, yet vaguely-stated desires to die in peace. I speak when and where I\u2019m invited, to both provider and lay audiences. In 2012 I introduced two new works: Windrum\u2019s Never Say Die Rap\u2122, an absurd musical statement of our quandary, and Windrum\u2019s Matrix of Dying Terms\u2122, a linguistic thanatological work introducing new terms that identify and name all sixteen fundamental dying situations, this to replace the sole word \u201cdying\u201d which fails to forecast or describe dying realities in our complex age.<\/p>\n Also in 2012 I took two steps regarding medical error in my presentations. I added a fourth trajectory to Joanne Lynn\u2019s three well-known charts<\/a> tracing the slope of deaths due to cancer, organ failure, and cognitive decline. I plotted a medical error trajectory based on my father\u2019s history and sent it to Dr. Lynn to let her know that I\u2019d expanded her work. Her email — which she\u2019s given permission to share — was telling: \u201cI had not yet seen someone add the error trajectory. I guess I see it as so commonplace as to be a part of most trajectories<\/em>, but bringing it out as a specific item has its uses [emphasis mine].\u201d<\/p>\n Figure 1.<\/strong> Updated Dying Trajectories That fall I associated medical error with a top ten causes chart for the first time, in a metaphorical manner, by adding a picture of a jumbo jet atop the causes stack plus a legend explaining what it signified. You\u2019re probably familiar with the \u201cX number of crashed jumbo jets daily\u201d metaphor used to dramatically convey the number of annual fatal medical errors. It\u2019s a vivid picture made relevant because aviation is rightly held up as a safety model that medicine often fails to emulate; no segment of society would tolerate one or more jumbo jets crashing daily; and the slow-mo image of daily crashes all year long, albeit horrid, makes an absurd point absurdly well. The graphic I made is based on a screen grab of the NEJM article\u2019s chart:<\/p>\n Figure 2.<\/strong> Wondering how to assess the numbers and present medical error deaths scaled to a chart, the best one can credibly do is float a proportionally sized box and footnote its limitations. In this treatment I divide 180,000 medical error deaths by 2,468,435 (the total number of US deaths in 2010) to yield a 7.3% medical error death rate, then multiply the chart\u2019s 597 per 100,000 deaths (data source CDC.gov) by 0.073, yielding 43.6 medical error deaths\u2014ranking medical error death fourth in the refigured chart (from which I\u2019ve removed the former number ten entry, suicide):<\/p>\n Figure 3.<\/strong> In trying to integrate medical error into the cause of death chart I\u2019m combining fatal medical error incident reporting to Medicare with the Centers for Disease Control cause of death data. I\u2019ve made some strides around end-of-life matters as a lay person, but I\u2019m at the limit of my abilities (and frustration) when it comes to solving how to integrate and correlate these two agencies\u2019 data sets so that anyone citing the data is forced to use the combined, correlated whole.<\/p>\n What would it take to account for medical error deaths while accurately reducing the number of deaths reported due to other causes? Since fatal medical error counts are widely disseminated and believed, why doesn\u2019t this data appear in CDC data used to compile top causes of death charts, automatically causing a medical error category to appear in them? Is it because medical error falls outside the scope of “disease”? Is it because of government silos? Some other reason? If you know, please add a comment to this article.<\/p>\n Casting about a bit more granularly, although it\u2019s unclear what NEJM\u2019s interactive chart\u2019s<\/a> Accidents category includes, I suspect that medical error is not rolled in; the chart breaks accidents into motor vehicle and non-motor vehicle. Is medical error hiding in the non-motor vehicle accident category?<\/p>\n\n
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\n![\"\"](\"https:\/\/i0.wp.com\/participatorymedicine.org\/journal\/wp-content\/uploads\/sites\/2\/2013\/04\/Windrum-figure-3.png?resize=609%2C456&ssl=1\" "\\"Windrum")
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\nI can\u2019t integrate the error value into the original chart data (can anyone reading this do so?), although we know of and can further deduce some number of medical error deaths erroneously recorded as due to disease (my dad\u2019s death certificate shows heart failure despite that nosocomial MRSA precipitated his demise). Fully incorporating error data would:<\/p>\n\n