Two Medical Error Reports-What We Can Learn From Them

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Recently, my colleague Holly Haines blogged about a medical error report issued by the Department of Health and Human Services which suggested that only 14% of medical errors are actually reported. In this post, I hope to continue that discussion by reviewing the HHS report in light of a 2010 report concerning incidents of medical errors in Medicaid patients.
According to the Minneapolis Star Tribune, “The earlier report looked at a random sample of Medicare patient hospital stays in just one month, October 2008. It found that 13.5 percent of the patients were harmed seriously, sometimes fatally. Examples of adverse events include internal abdominal bleeding caused by anticoagulant medications, hospital-acquired infections and failure to prevent bed sores from progressing to severe. An equal number of the Medicare patients suffered temporary harm — including delirium and hallucinations from narcotic pain medications, diarrhea from antibiotics and bleeding and bruising at the site of an IV insertion. Reviewing physicians judged 44 percent of the incidents as “clearly preventable” or “likely preventable.” The cost of treating the adverse and temporary harm events, the report projected, was about $4.4 billion annually — and this involved only Medicare patients. Other studies have projected unacceptably high rates of medical errors among other populations of hospital patients.”
When taken together, the two reports reveal a disturbing persistence and prevalence in medical errors. Some of this may be attributable to a stubborn unwillingness on the part of hospital personnel to take steps to change the culture. It’s certainly true that the technology is available to help avoid preventable medical errors. Yet, the technology can’t overcome a human unwillingness to change attitudes about medical errors and their prevention.

Jared Green
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