The 1999 Institute of Medicine Report

    The 1999 Insitiute of Medicine report on medical errors concluded that from 44,000 to 98,000 people die annually due to errors in inpatient hospital treatment.

     The Insitiute of Medicine report prompted hundreds of media citations.

     The Institute based its conclusion on two reviews of hospital charts from New York (1984) and Colorado/Utah (1992).

    In 1991, the Harvard School of Public Health studied 1984 data from 51 New York hospitals found that 3.7 % of hospital admissions had an edverse event due to medical error and 13.6 % of those errors resulted in death. A similar study of hospitals in Utah and Colorado found 2.9 % of hospital admissions had an edverse event due to medical error and 6.6 % of those errors resulted in death. Extrapolating to the number of hospital admissions in 1997 (33,600,000), the IOM arrived at the highly cited estimates for the upper and lower bounds for deaths due to hospital errors.

     The complete text of the Insitiute of Medicine study is available online:
To Err Is Human: Building a Safer Health System    Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, Editors;
          Committee on Quality of Health Care in America, Institute of Medicine
 As of May 2002, there are over 700 citations of the IOM report - see Headlines / Leads (this is slow to load)

  How Extensive is the Problem of Medical Errors?
    Read an interview with Lucien Leape , one of the authors of the Harvard study. According to Dr. Leape, the number of deaths from medical errors in hospitals could account for the equivalent to the death toll from three jumbo jet crashes every two days.    Public Health Reports, 1999; 114: 302-317    July / August, 1999

More Malpractice Than Lawsuits, New York Medical Study Suggests
   The New York Times, January 29, 1990
    Only 1.53 percent of patients who were harmed by medical treatment actually filed malpractice grievances.
  Citing: Hiatt et. al.,  A study of medical injury and medical malpractice. N Engl J Med 1989 Aug 17;321(7):480-4

Patient Safety in Surgical Settings: What Do We Know? Research Corner; Statistical Data Included
 AORN Journal   (Association of Operating Room Nurses)   January 1, 2002
   Most common adverse events listed: surgery (20%); medication errors (16%); nonsurgical treatment (14.8%),
    patient falls (8.8%), and nosocomial infections (7.5%).

Impact of Medical Mistakes May Have Been Exaggerated, Deadly Errors Still a Safety Concern
  The Charleston Gazette, July 25, 2001, Life; Pg. P2D;
Director of the VA Center for Practice Management and  Outcomes Research in Ann Arbor, Mich., estimates that between 5,000 and 15,000 deaths annually are due to errors. But he acknowledged those numbers are rough estimates.

Two Articles Revisit a Shocking Claim Made Last Year about Patients' Deaths.
       One Camp Suspects Exaggeration; the Other Thinks Figures Are Too Low.
Los Angeles Times July 5, 2000, Part A; Part 1; Page 3; Metro Desk
   A group of Indiana scientists, writing in today's issue of the Journal of the American Medical Assn., says those numbers were highly exaggerated.
   In a rebuttal, also published today in JAMA, Harvard scientist Dr. Lucian L. Leape, a member of the committee that released last year's report, wrote that the Indiana analysis is flawed--and that, if anything, the committee's numbers underestimate the problem.

Everyone's Nightmare Medical Errors Result in Tens of Thousands of Deaths Each Year.
     Worse, they're on the rise Daily News (New York) March 19, 2001; HEALTH & FITNESS; Pg. 43
        14 real-life mistakes a week in a typical ICU, three potentially dangerous, says (AHRQ).

 Study in this Month's Archives of Surgery Suggests Medical Errors at Hospitals May Be More Common than
    Previously Thought ALL THINGS CONSIDERED National Public Radio (NPR) November 21, 2000 , Tuesday
   . The government estimates that one in every 10 patients admitted to a hospital is the victim of at least one mistake, such as receiving the wrong drug. But a study in this month's Archives of Surgery suggests errors may be even more common than previously thought. (Audio)

Report Outlines Medical Errors in V.A. Hospitals  The New York Times, December 19, 1999, Section 1; Page 1
   Federal investigators have documented almost 3,000 medical mistakes and mishaps in less than two years at  veterans hospitals around the country, and more than 700 patients have died in those cases, the Department of Veterans Affairs says in a new report.

Deaths due to Cutbacks in Staffing  Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction.
             JAMA 2002 Oct 23-30;288(16):1987-93
   Excess patient load for nurses associated with a 7% increase in the likelihood of death for each excess patient per nurse.

   Failing to Follow Established Treatment Guidelines:

	Hypertension	Cholesterol	Diabetes	Heart Attack	Heart Failure	Top

Lack of Adherence to Established Guidelines:

The Quality of Health Care Delivered to Adults in the United States N Engl J Med  2003  June 26   348(26) :2635-45
      Review of the medical records for over 4600 patients in 12 cities showed that only 55% of recommended care was provided. Particular lapses in
care included:
    Underuse of Screening: Alcohol abuse, Breast Cancer, Colon cancer; Sexually Transmitted Diseases; Evaluation of Low Back Pain
    Underuse of Established Treatments: Diabetes; Asthma; Stroke; Congestive Heart Failure; Coronary Aretery Disease; Headache; Hip Fracture;
                        Cholesterol; Influenza Vaccination; Smoking & Alcohol Cessation Counseling
    Overuse of Therapies: Nifedipine after Myocardial Infarction; Prolonged Bedrest in Back Pain

Volume 349:868-874     August 28, 2003     Number 9
 Next

Clinical Research to Clinical Practice — Lost in Translation? N Engl J Med August 28, 2003    349(9):868-874. .
     Author Claude Lenfant examines the gap between medical knowlegde and medicine as it is practiced.

Hypertension
Inadequate management of blood pressure in a hypertensive population.   N Engl J Med 1998 Dec 31;339(27):1957-63
 Center for Health Quality, Outcomes, and Economic Research, Bedford Mass. Veterans Affairs Hospital
     Physicians in VA medical center failed to treat at least 40 % of patients according to established gudelines.

Failure of evidence-based medicine in the treatment of hypertension in older patients.
 Gen Intern Med 2000 Oct;15(10):702-9

Cholesterol
Analysis of the degree of undertreatment of hyperlipidemia and congestive heart failure secondary to coronary artery disease.   Am J Cardiol 1999 May 1;83(9):1303-7
"Current practice patterns in the management of CAD and CHF are inadequate."

Asthma
Inadequate therapy for asthma among children in the United States.
Pediatrics 2000 Jan;105(1 Pt 3):272-6 Most children with moderate to severe asthma in this nationally representative sample, including those with multiple hospitalizations, did not receive adequate asthma therapy.

Acute asthma: observations regarding the management of a pediatric emergency room.
 Pediatrics 1989 Apr;83(4):507-12  Inadequate assessment and inappropriate treatment of acute asthma have been implicated as contributing factors in morbidity and even deaths, the management of acute asthma, as practiced in an emergency room.

Myocardial Infarction

Treatment of myocardial infarction in the United States (1990 to 1993).
Rogers, et. al., Circulation, 1994 Oct; 90(4):2103-14
    Management of myocardial infarction in the United States does not yet conform to clinical trial recommendations.

Underuse of aspirin in a referral population with documented coronary artery disease.
    Califf RM, et. al.; Am J Cardiol. 2002 Mar 15;89(6):653-61.
    Despite substantial evidence that antiplatelet therapy saves lives and reduces adverse events in patients with coronary artery disease (CAD), use of the most widely available and lowest cost antiplatelet agent, aspirin, continues to be disappointingly low.

The underutilization of cardiac medications of proven benefit, 1990 to 2002.  Stafford RS, Radley DC; .J Am Coll Cardiol. 2003 Jan 1;41(1):56-61.
     Both national datasets demonstrate continuing underutilization of warfarin in atrial fibrillation (AF), beta-blockers and aspirin in coronary artery disease (CAD), and angiotensin-converting enzyme inhibitors (ACEIs) in congestive heart failure.. Although use is increasing, it remains lower than expected, and some increases noted in earlier years have slowed. Substantial public health benefits would result from further adoption of these effective therapies.
 

Diabetes
Frequency of Inappropriate Metformin  Prescriptions. JAMA Vol. 287 No. 19,  May 15, 200
 Institutional review of 100 metformin prescriptions showed 22 patients with absolute contraindications (CHF or renal insufficiency).

Adherence to 1997 diabetes screening guidelines in a large ambulatoryclinic,   Koll E, Hewitt JB.   Diabetes Educ 2001 May-Jun;27(3):387-92
       Only 57% of patients in large midwestern clinic screened for diabetes according to guidelines.

Congestive Heart Failure
Underutilization and clinical benefits of angiotensin-converting enzyme inhibitors in patients with asymptomatic left ventricular dysfunction.:
Am J Cardiol 2000 Sep 15;86(6):644-8

Underutilization of ACE inhibitors in patients with congestive heart failure. Drugs 2001;61(14):2021-33
Despite abundant evidence to support their efficacy and cost-effectiveness, angiotensin-converting enzyme (ACE) inhibitors are sub-optimally used in patients with CHF.

 What Kinds of Errors ? Wrong side surgery & Other Errors

ABO Blood  Typing Mismatch

Wrong Side Surgery

Wrong Procedure

Medication Errors

Laboratory Errors

Miscellaneous

TOP

ABO Blood typing mismatch:

 A report of 104 transfusion errors in New York State. Transfusion. 1992 Sep;32(7):601-6.
     Of 104 incident reports in the 22 month study period, there were 54 ABO-incompatible transfusions.

Donor Mix-Up Leaves Girl, 17, Fighting for Life New York Times,  February 19, 2003  Section A; Page 1
      Jesica Santillan, A 17-year-old girl,  is in critical condition after mistakenly being given a heart and lung transplant from a donor with the wrong blood type at Duke University Hospital in Durham, N.C.
     The donor had Type A blood, and Ms. Santillan Type O.

Suit Says Transplant Error Was Cause in Baby's Death New York Times, March 12, 2003  Section A; Page 23
     A year-old baby died in August at Children's Medical Center in Dallas after a surgical error destroyed her liver and doctors tried to save her with a transplant but mistakenly gave her a liver of the wrong blood type, according to a lawsuit filed on Monday.
     The case is the second to come to light in recent months in which a child died after a transplant team failed to take the most basic precaution of making sure an organ donor and recipient had compatible blood types.  The Duke case revealed that the most sophisticated medicine at an elite institution could be undone in a moment by a simple human error.
    In the last 15 years, although thousands of transplants have been done, only about a dozen mismatches have been revealed to the public or reported in medical journals. But the number may be an underestimate.

BLOOD ERRORS  - Blood Mix-Up Caused Death
Newsday (New York) NASSAU AND SUFFOLK EDITION  May 6, 2002, Pg. A06
   Twice within six days during April 2000, the lawsuit says, Ying Lung Chiu Wong of Chinatown was transfused with the wrong type of red blood cells and plasma. Shortly after the second incorrect transfusion, Wong died.
   A Newsday investigation, published last month, found that between 1995 and 2001, 441 hospital patients died following transfusions, including 78 who received the wrong blood.

The state-of-the-art computer was programmed to prevent mistakes
The Boston Globe December 11, 2000, METRO Pg. A1
     The machine beeped again and beamed a more urgent message: "Does not match . . . Do Not Use!" But the technician in the blood bank overrode the alarm.

Wrong side surgery

Make no mistake: Surgery patients need to be proactive
The Providence Journal-Bulletin (Providence, RI)   January 27, 2002, Health & Fitness; Pg. N-01
Surgeon operated on the wrong side of a man's brain.

USA TODAY, December 6, 2001, LIFE; Pg. 10D
  Since 1998 - three years after the problem became nationally known and a focus of patient safety initiatives
     -- there have been 136 reports of wrong sided surgery.

Doctors Face Sharp Penalty for Wrong Cut
The Palm Beach Post July 24, 2001; pg. 1A
    Doctor fined $10,000 last month by the state Board of Medicine for mixing up two patients. He performed a  procedure on each one that should have been done on the other.

Errors detailed in kidney removal
Boston Globe June 1, 1996, Saturday, METRO Pg. 1
 A surgeon at Quincy Hospital who removed the wrong kidney failed to check X-rays that would have revealed the error.

Neurosurgeon Supended after Wrong Side Brain Surgery
The Washington Post ; July 25, 1995; PAge Z05
  The chief of neurosurgery at a famous New York hospital has been suspended from his duties after he operated on the wrong side of a patient's brain for a malignant tumor.
   The patient, has been left with severely impaired vision and no awareness of her left side.
   A recent report in U.S. News & World Report ranked the hospital as the top cancer center in this country.

Hospital Told to Halt Surgeries after Amputation of Wrong Foot
New York Times. April 8, 1995, Saturday, Section 1;  Page 7;  Column 2
   Florida State Regulators ordered a hospital here where doctors amputated the wrong foot of a diabetic man in February to suspend elective surgery. In issuing the ruling, the  Florida Agency for Health Care Administration noted a series of mistakes in the last three months, including the amputation, the death of a man who was mistakenly taken off a ventilator and an
arthroscopic surgery on the wrong knee.

USA TODAY, June 16, 1995, Friday, FINAL EDITION, NEWS; Pg. 3A
USA TODAY, June 16, 1995, Friday, FINAL EDITION, NEWS; Pg. 3A

Wrong procedure

A 67-year-old woman mistakenly underwent an invasive cardiac electrophysiology study.
Ann Intern Med 2002 Jun 4;136(11):826-33 ;  Chassin MR, Becher EC.
  Among all types of medical errors, cases in which the wrong patient undergoes an invasive procedure are sufficiently distressing to warrant special attention. Nevertheless, institutions underreport such procedures, and the medical literature contains no discussions about them. This article examines the case of a patient who was mistakenly taken for another patient's invasive electrophysiology procedure. After reviewing the case and the results of the institution's "root-cause analysis," the discussants discovered at least 17 distinct errors, no single one of which could have caused this adverse event by itself. The discussants illustrate how these specific "active" errors interacted with a few underlying "latent conditions" (system weaknesses) to cause harm.
 The most remediable of these were absent or misused protocols for patient identification and informed consent, systematically faulty exchange of information among caregivers, and poorly functioning teams.

Medication Errors

A Lesson from Ben; Ben Kolb dies after being given the wrong medication during a routine ear surgery
 NBC News Transcripts, Dateline NBC (10:00 PM ET)  January 1, 2002
    Seven year old dies when he receives epinephrine injection instead of lidcocaine.

10 Common Prescribing Errors Consultant;  41(6) p. 766   May 1, 2001
Sound-alike Drugs;
Lack of Drug Knowledge;
Dose Calculation Errors;
Decimal Point Misplacement;
Wrong Dosage Form;
Wrong Frequency;
Use of Abbreviations;
Drug Interactions;
Renal Insufficiency;
Incomplete Patient History

Hospital Says Two Died in Nitrous Oxide Mistake
New York Times, January 17, 2002; Section B;  Page 1
 Two women at a hospital in New Haven died in one over the last week after getting
nitrous oxide instead of oxygen

Medical-Errors Issue Got High Profile Push
   The Boston Globe, December 13, 1999, NATIONAL; Pg. A1
    Dissussing death of 39-year-old Boston Globe health columnist died following a massive chemotherapy along
with other high profile malopractice cases.

 Lab errors

Hospital Admits Fatal Lab Errors; Incorrect Drug Doses Blamed for Deaths of 2 Men
The Washington Post, August 19, 2001, A SECTION; Pg. A02
   932 patients given incorrect Coumadin doses due to erroneous laboratory tests.

Med mal reform is bad medicine
Business Insurance  February 24, 2003
   Linda McDougal, the Wisconsin woman whose doctor mistakenly performed a double mastectomy on her even though she was cancer-free, has decided to become the poster child against medical malpractice tort reform.
   At the risk of sounding like a liberal, I'm with her.
   The tort system's fundamental moral purpose is to punish those who harm others, and, where feasible, to force them to pay restitution to their victims. Capping doctors' malpractice liability for noneconomic damages at $250,000-which is less than one year's salary for most of them-effectively removes the deterrent the tort system is meant to create.
 

 Other Errors

Porous Safety Net Allows Lethal Medical Mistakes   USA TODAY,   October 11, 2000, Pg. 1A
   An overworked nurse infuses the wrong type of blood into a patient.
   An experienced pharmacist puts the wrong drug in a child's medicine bottle.
   A less experienced surgeon blows a heart procedure that is performed more frequently, and flawlessly, down the street.

Determining Negligence an Inexact Science in Pennsylvania Malpractice Cases
Centre Daily Times; January 14, 2001
"According to a fairly recent Harvard University study, only one of 16 meritorious malpractice cases gets brought."

Serratia marcescens Bacteremia Traced to an Infused Narcotic   New Engl. J Med May 16, 2002
   Repiratory therapist infects 26 patients by drawing narcotic from intravenous lines.

Unexpected hypoglycemia in a critically ill patient (Insulin given instead of Heparin)
Ann Intern Med 2002 Jul 16;137(2):110-6
Administration of the wrong medication is a serious and understudied problem.
At approximately 8:15 a.m., Ms. Grant's (a pseudonym) ICU nurse heard coughing, entered her room, and found her moving her head and extremities in an uncontrolled manner. The nurse administered labetalol because the patient's systolic blood pressure was greater than 200 mm Hg. The ICU team arrived almost immediately, diagnosed a generalized seizure, administered intravenous lorazepam followed by midazolam, and emergently intubated the patient for airway protection. Serum electrolyte and arterial blood gas levels were measured, and computed tomography (CT) was done to rule out intracranial hemorrhage. Approximately 30 minutes after initiation of these diagnostic and therapeutic maneuvers, the laboratory notified the ICU team that the patient's serum glucose level was undetectable.
At 9:15 a.m., a nearly empty 10-mL vial of regular human insulin (100 U/mL) was found on the medication cart outside the patient's room. This finding, in conjunction with the persistent hypoglycemia despite aggressive glucose replacement, suggested that the patient's sudden deterioration had resulted from inadvertent administration of insulin.

  How Can Medical Errors be Reduced?        Top

   Agencies Concerned with Safer Medical Care:
      AHRQ   U.S. Agency for Healthcare Research and Quality (AHRQ) .
           WebM&M: Morbidity & Mortality Rounds . Health Care: Medical Errors & Patient Safety e  . .
      Institute of Medicine - (National Academy of Sciences) - The sponsors of Dr. Leape's 1991 report on medical
        errors discusses approaches to safer health care.
       Risk Management Foundation
      The Institute For  Safe Medication Practices (ISMP) .
      Joint Commission on Accreditation of Healthcare Organizations .
      United States Pharmacopeial Convention Inc. U.SP. has been setting standards for drugs since 1820 .

ARTICLES:

Improving Safety with Information Technology-    DW Bates, M.D., and A A Gawande, M.D., M.P.H.
           New Engl J Med  2003 June 19 348(25):2526-34
      This important article identifies areas in which readily availble technology can reduce errors by as much as 80%.
No less important are the 59 references discussing ways in which technology can reduce medical errors.

Residents' Suggestions for Reducing Errors in Teaching Hospitals
  NEJM  348(9):851-855  February 27, 2003  K.G.M. Volpp, M.D., Ph.D.  D. Grande, M.D.
   The authors identify 8 areas of concern and discuss changes that are necessary to avoid needess patient morbidity and morality.

 Mammogram Team Learns From Its Errors
     New York Times       June 28, 2002
    Kaiser Permanente radiologist improves accuracy by firing doctors who have high error rates
             - the result was 1/3  fewer cancers missed.

Report : National health-Care System Woefully Lacking; Tangled Maze: Institute Recommends an
   Overhaul to Bring 21st-Century Care to Patients
    Telegraph Herald (Dubuque, IA); March 2, 2001,  Pg. a2
  U.S. scientists have developed highly effective treatments for many diseases but too many Americans get inadequate, outdated or even unsafe therapy instead because the nation's health-care system is a tangled maze, the Institute of Medicine said in a scathing report Thursday.

Reporting and Prevention of Medical Errors
Prepared Statement of Lucian L. Leape, M.D. Harvard School of Public Health Subject Before the Senate Committee on Health, Education, Labor and Pensions; May 24, 2001

Harvard Prof Urges Hospitals to Spot, Curb Bad Doctors
The Boston Herald March 30, 2001
  "Every hospital has doctors whose performance is a concern," said Dr. Lucian L. Leape, professor at the
   Harvard School of Public Health.    "We do have problem doctors. Everybody has witnessed it. But everybody insists it is someone else's problem. It's a major issue and  hospitals have to take the primary responsibility."

Ideas & Trends: Do No Harm , Breaking Down Medicine's Culture of Silence
December 5, 1999, Section 4;  Page 1;  Column 1

Curtail Health Workers' Hours to Save Lives, Senators Urged
Chicago Tribune,  February 2, 2000, Pg. 7
   An expert on medical mistakes, which kill as many as 98,000 Americans every year, called last week for limiting the notoriously long hours medical personnel work.

10 Common Prescribing Errors Consultant;  41(6) p. 766   May 1, 2001
Sound-alike Drugs;
Lack of Drug Knowledge;
Dose Calculation Errors;
Decimal Point Misplacement;
Wrong Dosage Form;
Wrong Frequency;
Use of Abbreviations;
Drug Interactions;
Renal Insufficiency;
Incomplete Patient History

Patient-safety awards abound , but do they represent real progress in the fight against medical errors, or are they just for show?  Modern Healthcare;  April 22, 2002, Monday
''Part of the initial step in making progress is understanding that there's a problem. Now we know there's a problem.''

Pharmacist participation on physician rounds and adverse drug events in the intensive care unit.
Leape LL, et al. JAMA. 1999; 282(3):267-270. In group with Senior pharmacist participating in ICU rounds, The rate of preventable ordering Adverse Drug Events decreased by 66% from 10.4 per 1000 patient-days before the intervention to 3.5 after the intervention.
.                                                             Top

Reducing Errors in Health Care: Translating Research Into Practice
How Errors Occur.Medication Errors .Surgical Errors .Diagnostic Inaccuracies .System Failures
Improving Patient Safety. Adverse Event Monitoring .Computer-Reminders .Protocols .Promoting Safety .
AHRQ Publication No. 00-PO58   April, 2000
Nat'l Academy Press, Crossing the Quality Chasm: (2001) .

Reporting medical errors and adverse events; Research Corner.
AORN Journal    April 1, 2002 ;    JCAHO call for Safety

 VA tries to learn from its mistakes; Hospitals focusing on errors, not blame, to revolutionize care
The Baltimore Sun December 22, 2001;  Baltimore VA reports progress in decreasing medical errors.

Hospital Patient Safety Information Gives Consumers the Power To Make More Informed Health Care Choices;
PR Newswire January 17, 2002 , Thursday
Leapfrog Group Unveils First Results of Unique Survey: Initial Focus on Six Regions including Atlanta, California, East Tennessee, Minnesota, St Louis, and Seattle-Tacoma-Everett   http://www.leapfroggroup.org

In search of safety : Nursing Economics January 1, 2002 http://www.premierinc.com/

Building an Electronic Network of Care; Group Seeks to Cut Medical Errors by Sharing Information While Guarding Privacy   Washington Post, December 12, 2001

State awarded $ 4.5m to fight medical errors.                                                             Top
The Boston Herald October 30, 2001; NEWS; Pg. 016
The three-year project will seek more information about how errors occur and about how patients, doctors, hospital officials and others can make the system safer.

Paths to reducing medical injury: professional liability and discipline vs. patient safety -- and the need for a third way.   Journal of Law, Medicine & Ethics September 22, 2001; Pg. 369

Health Care Quality and How to Achieve It
        Comments by Kenneth Shine, M.D. President of the Institue of Medicine

Oops, Wrong Patient: Journal Takes On Medical Mistakes
The New York Times  June 18, 2002
        The patient had been on the operating table for an hour. Doctors had made an incision in her groin, punctured an artery, threaded in a tube and snaked it up into her heart. Now they were stimulating her heart electrically, to test for abnormal rhythms.
        The phone rang: it was a doctor from another department. What, he asked, were they doing with his patient? There was nothing wrong with her heart.
  Annals of Internal Medicine series highlights case reports of errors to focus on what can be done to reduce injuries.

To err is human : How to prevent medical errors.
Patient Care June 15, 2001; Pg. 95
  http://www.usp.org/reporting/review/qr66.pdf .1000 name pairs that have been confused on prescriptions
      have been   identified
  http://www.fda.gov/cder/cdernew/ listserv.html and MedWatch at http://www.fda.gov/medwatch
  http://www.fda.gov/cder/cdernew/listserv.html

           GREED !

OPERATING PROFIT - Mining Medicare
How One Hospital Benefited on Questionable Operations
New York Times August 12, 2003 A-1  Jonathan Kirshner for The New York Times
     Could it possibly be that doctors at his hospital in Redding, Calif., were cracking open the chests of perfectly healthy people?
     Tenet Healthcare agreed to pay $54 million to the government to resolve accusations that Redding Medical doctors conducted unnecessary heart procedures and operations on hundreds of healthy  patients.
     Until federal agents raided Redding last fall, Tenet's business model was based on maximizing the dollars it could collect from Medicare, the nation's biggest buyer of health care. And Medicare's complex formulas — the template for private insurers, as well — reward some kinds of health care more richly than others, and few more richly than cardiac care.
      On multiple occasions, staff cardiologists raised concerns about the heart program and asked for an independent peer review. None was undertaken.

PROFESSIONAL DISCIPLINE                                                          Top

National Practioner Databank: (See Federal Law )
 Intro to DataBank-Hartford Courant-Reports by State.State Ranking.Links to State Regulators.
   questionbledoctors.org. 13 states have online versions of their lists of disciplines doctors.
 Hartford Courant Series: White Coats / Dark Secrets . 1 .2. 3 .4 . 5 . 6 . 7 . 8 . State by State Reports.

Do house officers learn from their  mistakes?
    JAMA 265(16):2089-94 (1991 Apr 24) Wu AW, Folkman S, McPhee SJ, Lo B
 Residents will not tell teaching physicians of 46% of their errors for fear of the consquences to their careers. 31 % of these errors resulted in deaths in this article from the San Francisco VA hospital.

A Free Ride for Bad Doctors
 New York Times Editorial - Op Ed 3/4/2002  By Sidney M. Wolfe, M.D.; Public Citizen - Health Research Group .
 Only a small percentage of doctors account for most of the money paid out in malpractice cases. Yet, only a small fraction of these doctors are disciplined by state medical boards.

Massachusetts: Pharmacists Rarely Disciplined by Board
The Boston Globe, April 16, 2002 - 10% of pharmacy errors resulted in discipline

3 Doctors Are WarnedBY Board                                                              Top
  The Boston Globe January 27, 2002

Disciplining of physicians under review; Maryland legislators to begin hearings on reforming system;  'Dramatic changes' needed; Baltimore Sun;  December 2, 2001 Sunday
Baltimore physician who has  never faced disciplinary action or a restriction of his practice despite 18 malpractice suits during the past two decades -- half of which led to payments that total more than $2 million.

Inept Physicians Are Rarely Listed as Law Requires
The New York Times, May 29, 2001,  Section A; Page 1
A federal program to protect patients from incompetent doctors is failing because health maintenance organizations and hospitals rarely report those doctors to the government as they are required to do, federal investigators say.

 US government warns practitioner database underused
 The Lancet;  June 9, 2001, Pg. 1855
US managed care organisations (MCOs) are violating federal law by routinely failing to report poorly performing doctors to the National Practitioner Data Bank (NPDB), according to a study by the US Department of Health and Human Services (DHHS) Office of Inspector General.    See http://oig.hhs.gov/oei/reports/a521.pdf

 2 Doctors Suspended After Surgery on Wrong Side of Man's Brain
    The New York Times , February 26, 2001;  Section B; Page 5

OPERATING BEHIND CLOSED DOORS - The Virginian-Pilot June 23, 2002 Sunday Final Edition, Pg. A1
The Virginian-Pilot first reported in July 2001 news of a state investigation of Dr. Robert G. Brewer, a surgeon whose medical license later was revoked. Over the past 11 months, medical reporter Liz Szabo has interviewed dozens of patients and their families about problems with Brewer's work. Her review of nearly 2,000 pages of medical charts and court records reveals that serious problems with Brewer's surgeries had surfaced as early as 1990, yet Brewer continued operating on patients??? for 11 years. Today, The Pilot presents a special eight-page report on harm caused by one doctor and failings in the system that allowed him to continue working. Full text online - Requires registration.

Medicine's Code of Silence
Los Angeles Times; August 24, 1995,  Part A; Page 1
  An eight year old boy died when his anesthesiologist fell asleep suring his operation.
  The Hospital was top-ranked by professional groups and consumers.
 The doctors colleagues had informed the Hospital on at least six occasions in the past that the same anestheiologist appeared to be sleeping during operations, and handled the anesthesiologist's problems internally rather than notify state regulators.

    Top

Links - Medical Errors and  Preventing Medical Errors
      Preventing Medical Errors:  Abstract from Nursing Learning Network course
       Home Study Educators - Preventing Medical Errors (50 Page PDF with annotations)
      New York Medical College Family Practice Residency - Guide for preventing medical errors (90 page PDF - LONG DOWNLOAD!)
      1999 Insitiute of Medicine report How the IOM concluded that from 44,000 to 98,000 die annually from medical errors
       Media Citations to the IOM Report.