Flatlined: Resuscitating American Medicine

Chapter 9. Dangerous Hospitals

P oor management of medical resources is not only expensive but dangerous . In 1999 the Institute of Medicine published To Err Is Human, a landmark book based on a study of medical errors.1 The institute concluded that medical errors in hospitals kill between 44,000 and 98,000 people per year. According to the authors, this number of deaths is equivalent to the death toll from the crash of one jumbo jet per day, making medical error in the United States the fifth-leading cause of death (if we apply the larger estimate of victims). They also concluded that the primary problem was not bad doctors but bad systems. The Institute of Medicine’s conclusions were based upon studies that reviewed the medical records of 30,121 patients in New York in 1984 and 15,000 patients in Colorado and Utah in 1992.2 While these figures were old when To Err Is Human was published in 1999, everyone believed that they had remained accurate, although critics argued that the numbers were inflated because some of the patients would have died anyway—cold comfort to the patients.3 As a consequence of this study, the institute set a five-year goal of reducing death from medical error by 50 percent. Though there has been some progress from voluntary programs, no one believes that this goal has been met. Errors of Omission, Lapses in Quality The Institute of Medicine based its conclusions upon studies that primarily examined errors of commission—that is, of doing something wrong. 77 9 Dangerous Hospitals A hospitalized patient has a vastly greater chance of being the subject of a medical error than of having his bag misplaced by an airline. CH009.qxd 10/7/08 9:58 AM Page 77 It did not calculate the results of errors of omission—the failure to do something needed. In a hospital, an error of commission might be a blood-stream infection caused by inserting an intravenous line or giving a patient the wrong dose or the wrong medication. An error of omission might be to fail to recognize that a patient is getting into trouble from a blood clot in the wound after surgery or failing to prescribe a medication to prevent a second heart attack at the time of the patient’s hospital discharge. In the most recent systematic data on hospital error, investigators who added the number of errors of commission and omission estimated 2004’s preventable death toll at 284,000.4 If this is true, then error in hospitals is the third-leading cause of death in the United States behind heart disease and cancer. In 2007 the airline industry reported a rate of misplaced bags of 7.93 mishandled bags per1,000 passengers, increased from 3.84 bags per 1,000 passengers in 2002. In 2007 the Institute of Medicine estimated that hospitalized patients are the subject of one medication error per day—and medication errors are just one kind of error.5 A hospitalized patient has a vastly greater chance of being the subject of a medical error than of having his bag misplaced by an airline. Financially Unstable and Particularly Dangerous In all the hospitals where I worked, safety fluctuated with the hospital’s financial status. It was always worse when the books did not balance. When hospitals are financially distressed, operational procedures break down. There is little in the literature to back up this statement, but experience bears it out. When hospitals are under financial distress, they invariably lose their regular nursing staff because one of a hospital’s first reactions to a budget shortfall is to force nurses to double up on the number of patients they care for. (More than half of a hospital’s cost is for personnel, mostly nurses, so labor costs have to be cut.) When this happens, regular nurses quickly burn out because they are overworked and feel they cannot do a good job for their patients. Then regular nurses are replaced with temporary nurses or new hires. My colleagues and I always dreaded working with temporary nurses because they did not know the hospital’s procedures. WHY HEALTH CARE IS SO EXPENSIVE 78 CH009.qxd 10/7/08 9:58 AM Page 78 The medical literature has established a clear relationship between patient mortality, low nurse-staffing levels, and deficient nursing education .6 High personnel turnover in...