Little Progress in Reducing Deaths from Preventable Medical Errors

While progress is being made in certain areas of preventable hospital errors, such as dramatic reductions in the rate of central line infections and other hospital associated infections, the overall death rate from preventable medical errors  has not decreased much since the Institutes of Medicine’s (IOM) landmark report, To Err is Human was released nearly 15 years ago. This was the conclusion of a panel of medical experts who testified before the Subcommittee on Primary Health and Aging of the Senate’s Committee on Health, Education, Labor and Pensions at a hearing on July 17, 2014. In fact, the rate may even have increased.

Preventable Errors

Witnesses referred to three studies conducted  from 2011 to 2013 which showed that the number of deaths at hospitals from preventable errors may actually be as high as 400,000 annually, which is significantly higher than the 98,000 annual deaths the IOM report estimated.  The 400,000 number comes from a study conducted by Dr. John James which was published in the Journal of Patient Safety in September of 2013.  Dr. James testified that he got to that number from some pretty simple math. “There were 34 million hospitalizations in 2007, of which approximately 0.9% involved lethal adverse events, and of those approximately 69 percent on average were judged to be preventable,” said Dr. James during his testimony.  He concluded that this leads to 210,000 deaths from preventable medical errors. When he corrected for the missed deaths from medical errors that current tools do not catch, the number came out to be something more like 400,000 lives which “are shortened by preventable adverse event each year,” he stated.

HHS’ Office of the Inspector General estimated that medical errors caused the deaths of nearly 180,000 deaths to Medicare beneficiaries each year in a November 2011 report based on 2008 data, according to Dr. Ashish K. Jha who is also a professor of Health Policy and Management at the Harvard School of Public Health.  Again that number is significantly higher than the 98,000 estimated by the IOM.  Finally a New England Journal of Medicine study of hospitals in North Carolina “showed that there had been little evidence that harm had decreased substantially over the 6-year period,” according to the testimony of Lisa McGiffert, Director of Patient Safety for Consumers Union.

Recommendations

Among the recommendations to reduce this number was better reporting of medical errors, transparency of that reporting to the public and the use of software to go through electronic medical records to uncover medical errors.  All of the witnesses provided anecdotal evidence of medical errors that lead to death, but would not be reported using existing  reporting requirements and software.

One recommendation made by Dr. James and Lisa McGiffert was the establishment of a National Patient Safety Board similar to the National Transportation Safety Board.  The National Patient Safety Board would track the any fragmented safety programs and provide a comprehensive coordinated approach to reducing the number of medical errors, said McGiffert.

Transparency and the public availability of safety data was a recommendation made by Dr. James. He stated that patients have a right to know the safety record of their physicians and facilities where they receive care such as outpatient clinics and nursing homes as well as hospitals.   Dr. Jha recommended more mining of electronic health records to obtain evidence of medical errors. He pointed out that software currently exists that uses data in medical records to identify when a medical error occurred.  Dr. Jha advocated requiring the use of these tools for automated patient safety monitoring  as a part of the meaningful use requirements predicting that it would have a dramatic effect on the reporting of the number of medical errors.

These recommendations were advocated by the witnesses because each related a story of a person  who died as a result of a medical error in a hospital that would never have been reported as a medical error under the current reporting mechanisms.  Dr. James became an advocate of patient safety after his son died due to a medical error.  Dr. James discovered the error by examining his son’s medical records and saw that another physician missed prescribing an essential medication. Dr. James’ point though was that with the current reporting requirements, the failure of one of his son’s doctors to prescribe a medication would not have been reported as a medical error, even though an examination of the medical record indicated it was.

Younger People Travel to Urban Hospitals for Care

In 2010, 6.1 million people who lived in rural areas were hospitalized, and of that number 60 percent sought care at hospitals in rural areas and 40 percent traveled to urban areas for hospital services, according a new report from the Centers of Disease Control and Prevention (CDC). The report, Rural Residents Who Are Hospitalized in Rural and Urban Hospitals: United States, 2010, examined the differences in who sought care in urban areas as opposed to rural areas, what type of care was provided by hospitals in both regions to rural residents, and what type of care settings rural residents were discharged to by urban and rural hospitals. Interestingly, the death rate of rural residents admitted to a hospital in an urban area was the same as a rural resident admitted to hospital in a rural area; 2 percent.

Travel for Care

Elderly rural residents seek care in rural areas, according to the CDC’s report. Roughly 51 percent of rural residents 65 years or older who were hospitalized in 2010 were hospitalized in a rural hospital. A majority of rural residents who were hospitalized in 2010 and were 64 years of age or younger were hospitalized in an urban hospital. The CDC stated that prior research showed that older patients (patients over 65 years of age) were less likely to travelfor hospital services due, in part, to barriers imposed by traveling to urban areas and a preference to remain closer to their homes.

Service Received

A little more than one-third, 38 percent, of rural residents hospitalized in a rural hospital received surgical or nonsurgical procedure during their stay. Rural residents hospitalized in urban hospitals received far more surgical and non-surgical services. Seventy-four percent of rural residents in an urban hospital received a surgical or nonsurgical procedure, and rural residents in urban hospitals were three times as more likely to receive three or more procedures than rural residents in rural hospitals. The CDC referred to a study that showed that due to economies of scale and volume of patients, many rural hospitals do not offer many types of diagnostic tests or specialized treatments.

Discharges

Rural residents in rural hospitals were less likely to be discharged to their home and more likely to be discharged to another short-term hospital or to a long-term care institution. Only 63 percent of rural residents receiving care a rural hospital were discharged to their home while 81 percent of rural residents in urban hospitals were discharged to their home. Only 3 percent of rural residents in an urban hospital were transferred to another short-term hospital while 7 percent of rural residents in a rural hospital were transferred to another short-term hospital. Repeating the pattern, 14 percent of rural residents who received services from a hospital in a rural area were discharged to a long-term care institution, while only 8 percent of rural residents who received care in an urban hospital were discharged to a long-term care institution.

Earlier Study

The CDC used data from the National Hospital Discharge Survey, which has been conducted annually from 1965 through 2010, for this study. An earlier study by the CDC using the same data showed that overall only 12 percent of the 35 million hospitalization in the U.S. in 2010 were in rural hospitals (see Rural hospitals serve fewer patients, perform fewer services that urban counterparts, reported on April 24, 2014). The earlier report found that the percentage of rural hospitalizations was not only slightly less than the overall rural population, which in 2010 was 17 percent of the country. Data from that study also determined that fewer services were performed in rural hospitals, with only 6 percent of the 51 million inpatient medical procedures performed in 2010 occurring in rural hospitals.

Maryland to Cover Gender Reassignment Procedures for State Employees

Maryland has dropped its exclusion from coverage for sexual identification transition-related care from all health plans for state employees and has replaced it with a gender dysphoria benefit. Maryland becomes the third state to provide coverage for sex-transition related health care, joining Oregon and California, which began providing coverage in 2013 and 2014 respectively. The change in Maryland became effective on July 1, 2014, according to a report in the Baltimore Sun, but was not publicly announced until July 22, 2014.

The change was the result of a legal claim made by Sailor Holobaugh who was denied coverage for a medically necessary bilateral mastectomy. Mr. Holobaugh is a clinical research assistant in neurology at the University of Maryland School of Medicine in Baltimore. In November of 2012, Mr. Holobaugh paid $6,000 for the surgery out of his own pocket. He sought reimbursement by making a claim through the State of Maryland Employee and Retiree Health and Welfare Benefit plan. The claim was denied based on an exclusion in the plan for “any procedure or treatment designed to alter an individual’s physical characteristics to those of the opposite sex,” according to a press release from FreeState Legal who represented Mr. Holobaugh in legal actions on this issue. Mr. Holobaugh argued that this exclusion violated Maryland’s Governor Martin O’Malley’s (Dem.) 2007 executive order prohibiting discrimination in state employment on the basis of gender identity. Maryland agreed to reimburse Mr. Holobaugh for his surgery and other transition-related medical costs to date and apply the new gender dysphoria benefit to all of its employee health plans instead of fighting Mr. Holobaugh’s claim in court.

Gender Dysphoria Benefit

The new gender dysphoria benefit covers treatments that are medically necessary and includes coverage of hormone replacement therapy, a variety of surgical procedures, and other transition related care options. The standard for medical necessity under the benefit closely tracks the standards of care established by the World Professional Association for Transgender Health, which is internationally recognized as the leading authority on health care for transgender persons according to FreeState Legal. The benefit applies to all state employees and retirees as well as their spouse and dependents.

“I am thrilled that people who serve Maryland as state employees now have increased access to health services, and that they can extend these benefits to their dependents,” said Holobaugh. Jer Welter, Managing Attorney for FreeState Legal, however, noted that “there is still work to be done, including the elimination of similar transition-related care exclusions in the Maryland Medical Assistance (Medicaid) program and in policies issued by private insurers regulated by the Maryland Insurance Administration.” FreeState Legal is a legal advocacy organization that seeks to improve the lives of low-income lesbian, gay, bisexual, transgender and queer Marylanders.

FDA: Avoid Powdered Pure Caffeine

Powdered caffeine, which is commonly sold over the internet and in other locations should be avoided, according to a Food and Drug Administration (FDA) release. Using ever stronger language, the FDA said the individuals with pre-existing heart conditions should not use the products. The FDA states that these products are almost 100 percent caffeine and even small amounts can be lethal. The FDA stated that it is aware of the death of a teenager in Ohio who consumed one of these products.

Dosage Amounts

The FDA said that consumption of a very small amount of these products can cause an accidental overdose. A single teaspoon of pure caffeine can be the equivalent of 25 cups of coffee. Furthermore, the FDA said that it is nearly impossible to accurately measure powdered caffeine with common kitchen tools. The Washington Post reported in a story on the death of an Ohio teenager that “a mere 1/16th of a teaspoon can contain 200 milligrams of caffeine, roughly the equivalent of two large cups of coffee.”

Symptoms

The symptoms of caffeine overdose include rapid or dangerously erratic heartbeat, seizures, vomiting, stupor, disorientation, and death, according to the FDA. The severity of these symptoms is much greater than simply drinking too much coffee, tea or other caffeinated beverage, said the FDA. An individual who believes they have consumed too much caffeine and are experiencing one of these reactions should seek immediate medical care.

Death of Teenager

A county coroner in Ohio ordered additional tests after a bag with white powder was discovered in the home of an Ohio teenager who unexpectedly died of seizures and an abnormal heart beat. Those tests revealed that the teenager had taken more than a teaspoon of the powder, or about 16 times the recommended dose, according to a report on Cleveland.com. The Washington Post article stated that the same corner’s report said that the teenager “had more than 70 micrograms of caffeine per milliliter of blood in his system, as much as 23 times the amount found in a typical coffee or soda drinker.”

The Substance Abuse and Mental Health Service (SAMHSA) reported that the number of emergency department visits associated with the use of energy drinks has doubled; going from 10,678 in 2007 to 20,783 in 2011. SAMHSA described energy drinks as flavored beverages containing high doses of caffeine. Caffeinated powder, which the FDA is advising people not to use and the cause of the death of the teenager in Ohio, is sold as a dietary supplement and as such is not as heavily regulated as other substances. Users routinely added it to drinks as a way of weight control.

The FDA would like people to report adverse events associated with the use of powdered caffeine by calling them at 240-402-2405 or by email at CAERS@cfsan.fda.gov.