Medical errors and malpractice are the third leading cause of death in the United States, according to a 2016 Johns Hopkins University study. The importance of this statistic was highlighted in a recent review of Boston Children’s Hospital that found 3 serious medical errors in 2017, and 1 that resulted in death.
The release of this report, following state and federal reviews, reminds us that medical errors and malpractice do not only hurt adult patients, but more vulnerable children. These problems must be addressed not only by Boston Children’s Hospital, but health care facilities nationwide.
Report Points to Snail-Like Pace of Change
All 3 of the medical errors cited in the review involved medication or dosage mistakes. These problems meant the hospital risked being dropped from Medicare if they were not corrected. While Boston Children’s Hospital maintained its Medicare status, these problems demonstrate that drug-related errors can happen all too easily.
The most serious case involved a young patient who was supposed to be given an antibiotic at noon. The child was not dosed with this medication until 2 in the morning, and later died from sepsis, a serious infection. The patient was seriously ill when admitted to the hospital and needed to be on a breathing machine and dialysis. The nurse treating this patient thought a doctor had said to not give the patient an antibiotic yet, but this was not the case.
Following this tragedy, the hospital sent an email to all doctors and nurses in the intensive care unit, reminding them that changes in medicines and dosages had to be written. Yet as investigators noted, this critical message was not sent to all caregivers hospital-wide until much later.
The other errors involved 2 children who were given too much Propofol, a type of anesthetic. The first case happened in January, when patient was injected by a doctor who did not realize the syringe had 2 doses. A committee looking into the incident stated that the hospital needed a policy that syringes only contain 1 dose of anesthetic appropriate for size of patient. Yet this guideline was not put into place, which resulted in a second patient overdose later in 2017.
The hospital has adopted new procedures for treating sepsis and dosing the anesthetic, yet these problems point to much larger issues implementing change in hospitals. About 1.5 million people may be injured every year due to drug dosing problems.
As the investigation of Boston Children’s Hospital suggests, hospitals must act much more quickly to correct problems, understand why the errors occurred, and institute procedures to ensure they will not happen again.
The Secret Statistic
Medical errors account for over 250,000 deaths every year, meaning they cause more fatalities than accidents, strokes, and respiratory problems. While cancer and heart disease have a higher mortality rate, we cannot ignore that 9.5 percent of deaths in the United States are due to mistakes that occur during caregiving.
The Johns Hopkins study authors suggest that the true severity of this problem is unknown, because medical error is not included on death certificates. Medical error fatalities and other statistics are not systematically collected as a means of assessing our national health and healthcare system, which skews how research studies and dollars are allocated. Since cancer and heart diseases are on the top of the list, they receive more dollars for prevention and research, while medical error goes ignored.
The Johns Hopkins researchers emphasize that errors should not automatically be faulted on poor-quality health care providers. Instead, many of these problems are found within the health care system itself, such as miscommunications, failure to coordinate among caregivers, and a lack of guidelines to assure all health care providers use the same standard procedures.
Further, there are barriers to admitting error in medical culture, since medical students are told there should be no mistakes, which leads to problems being hidden. The system must change to allow for admission of error and increased transparency, both of which will help healthcare providers to understand when and how problems occur.
The findings at Boston Children’s Hospital are symptomatic of bigger issues within our healthcare system, and the fact that hospitals must change their procedural and institutional culture. As always, it is only by admitting our mistakes that we can hope to learn from them.