The CBS Evening News (5/3) reported that research indicates that “medical errors are now the third largest cause of death behind heart disease and cancer.”
USA Today (5/3, O’Donnell) reports that the study authors “wrote that strategies to reduce death from medical care should include making errors ‘more visible’ when they occur, having remedies available to ‘rescue patients,’ and making errors less frequent by following principles that take ‘human limitations’ into account.”
www.usatoday.com/story/news/politics/2016/05/03/second-study-says-medical-errors-third-leading-cause-death-us/83874022/
According to the Washington Post (5/3, Cha), “In 1999, an Institute of Medicine report calling preventable medical errors an ‘epidemic’ shocked the medical establishment and led to significant debate about what could be done.” The institute, “based on one study, estimated deaths because of medical errors as high as 98,000” annually. The new research, published in the British Medical Journal, “involves a more comprehensive analysis of four large studies…that took place between 2000 to 2008.”
www.washingtonpost.com/news/to-your-health/wp/2016/05/03/researchers-medical-errors-now-third-leading-cause-of-death-in-united-states/
The New York Times (5/3, Bakalar) “Well” blog reports that the researchers “estimated that an average of 251,454 deaths per year in the United States are caused by medical error.”
Blogfinger Medical Commentary by Paul Goldfinger, MD, FACC:
It’s been known for about thirty years that there are nearly 100,000 deaths per year due to medical errors, with most reports coming from hospitals. Newer tabulations have been used to generate the latest number (above) of about 250,000. The Department of Health and Human Services reported that 180,000 Medicare recipients die each year from medical errors. Some might quarrel with the numbers, but certainly it is clear that a huge number of patients are dying due to medical errors.
The U.S. has a national network of medical schools that tend to be of high quality, and the admissions are so competitive that only smart people get in, so I don’t think that dumb doctors are the cause of these findings.
The numbers that we are discussing tend to be due to errors of omission or of commission, and such errors often begin with poor communication, carelessness, wrong diagnoses, poor training of personnel, and ineffective monitoring routines. Errors may involve nursing or support personnel as well as physicians. Sometimes a sequence of mistakes results in a death, so culpability may be spread around in a particular case.
And then there are the inadequate designs of medical practices including a lack of sufficient safety nets in healthcare facilities of all kinds. In the new healthcare system, there are challenges due to huge numbers of patients, assembly line procedures to augment profits, and corporate management with no knowledge of patient care.
Since stupid doctors are not usually the problem, I have found that the main malfunctions are wrong incentives—especially financial, inattention to detail, ethical lapses, rushing to meet deadlines, sloppiness in procedures and care, and, today, a breakdown in the time-tested details of care. Doctors have become employees. They used to determine the procedures that govern care in hospitals and offices, but now managers who don’t understand how medical care is supposed to work have taken charge.
The safeguards that protect patients are seriously deficient across the country. There are no comprehensive mechanisms to investigate mistakes, and there are no reliable reporting procedures to identify errors and evaluate them. Even in malpractice suits, when evidence of mistakes are often disclosed, legal gag orders prevent the information from getting out.
When I started in practice, my background was at first-rate training institutions where I rarely saw errors. The same was true in the large military hospital where I worked, but things were much different out in the real world of private practice where, as a consultant, I saw mistakes on a daily basis. In US hospitals, over the years, many programs were instituted to identify errors such as establishing intensive care monitoring committees to round in the ICU/CCU to look for quality issues, and we found plenty of questionable care.
As ICU/CCU chairman of our new committee, I recall going to the medical staff to inform them of our rounding plans. The President of the staff, an arrogant surgeon, reacted by saying, “Nobody is gaining access to my patients’ charts.” But we won that battle and were empowered to intervene when necessary. We also were enablers for our highly trained nurses to be able to question the orders and plans coming from the doctors.
Other procedures to prevent errors have been devised, but obviously, not enough is being done.
The surgeon from Johns Hopkins who was the lead author of the study above pointed out that our society spends fortunes on cancer and heart disease care, but very little on the third leading cause of death——medical errors. This problem has not been widely recognized, and it is an issue around the world. It is likely that many of the errors are preventable if only funds were available to tackle the issue.
I might add that a huge arena which has not been analyzed at all is that of the private medical office practice. Most doctors are trained in hospitals. Then they open offices where there are many quality challenges. Some doctors have been very good at following the standards of good medicine, while other office practices are awful, dangerous places. Today, with corporate incompetents in charge of offices, I find that it is rare for me to interact with an office practice and not find something worrisome going on.
What to do? The first thing is for organized medicine to reclaim the traditional doctor-patient relationships and then get strict with doctors regarding their priorities (“Always place the patient first” is a traditional primary value of the medical profession.) And the government needs to finance innovative approaches to saving lives threatened by errors.
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Prior authorization is a major practice burden for doctors. Have you heard of it? Have you experienced it?
Posted in Blogfinger Medical Reports, Blogfinger Presents, tagged Blogfinger medical commentary on April 14, 2018|
Internet cartoon.
Medical practices spend an average of two business days a week per physician to comply with health plans’ inefficient and overused prior-authorization (PA) protocols. One-third of practices employ staffers who spend every second of their working hours on PA requests and follow-ups. But some relief appears to be coming, as the AMA and joins forces with some payers to fix this broken process. Read more at AMA Wire®.
This quote is from the AMA Morning Rounds: “Physicians have, for many years, expected to face prior-authorization hurdles for a few new or unusually expensive medications or tests. But, more recently, insurers have rapidly added PA requirements to more and more treatments,”
Blogfinger Medical Commentary: Paul Goldfinger, MD, FACC
Some of you may have experienced rejection of a particular prescription drug by your drug plan. But such rejections typically get reversed by enlisting your doctor’s help, and that would require his time and that of his staff to deal with the insurance company. The process is called “prior-authorization.”
In the article above, from the AMA, they discuss the problem from the perspective of the physician, but I have experienced it myself, from the perspective of the patient.
And, without a doubt, the episodes of prior authorization have increased noticeably for patients, but, as discussed above, also for the prescribing physician and his staff.
And now we see insurance companies questioning even cheap generics or chronically used stable medications, and the issue isn’t always the drug choice itself.
For example, I recently ran into this situation related to my use of a high blood pressure medication that is perhaps the number one or number two choice prescribed by doctors for their patients with hypertension.
In my case, I was doing very nicely with two 5 mg. tablets each morning of that drug (10 mg per day)—lisinopril, an ACE inhibitor. However recently my doctor wanted me to increase the dose from two tabs each day to two tabs twice per day (20 mg per day), ie 4 tabs per day instead of 2.
So I would need 360 tabs per 90 days instead of 180 tabs per 90 days—-a perfectly reasonable dose change. I was notified that they would not send me my medication because it required the prior authorization process. Meanwhile I was running out of medications while the plan would try to get my doctor to respond. And the drug plan was contacting me by mail and phone messages to raise the PA alarm.
I couldn’t understand why this innocuous dose change was a problem—it’s a cheap drug with a zero copay. I was baffled, so I called the company, but the customer service representative couldn’t figure out why prior authorization was being applied to my prescription. She advised me to wait for the process to play out. This was unacceptable.
I thought about the problem, and it dawned on me that maybe the number of pills was the issue, and not the medication itself.
Maybe the problem was the 360 tablet requirement, every 90 days. Being a physician I was able to call and speak to a pharmacist at the mail order plan. He verified that the number of pills was the problem, not the dose.
So I asked if we could change the tablet size from 5 mg. to 10 mg, making the daily dose two tabs each day. He said “fine” and a few days later I received 180 of the 10 mg tabs.
But the warning letters and phone messages continued. Finally I called the “prior authorization” department and told her that I fixed the problem myself. And she said, “Oh, when you get the letters and phone calls just ignore them until the matter is fully resolved.”
The best resolution available for most patients is to make sure that your doctor’s office staff has done their job with the paper work. It might be easier to resolve if you buy your meds from a local pharmacy. If you have a mail order pharmacy, as I do, and you are running out of pills, one of the local pharmacies will help you get a temporary supply, assuming that the left hand and the right hand at your drug company can resolve the problem.
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