Preventable Medical Errors

A recent post regarding a medical error that occurred with a kidney transplant patient caught my eye.  I was interested because of the position the author had taken on the subject.  Without looking at his profile I assumed he was an administrator of a hospital.  You can read the post and comments here. This story is a case of a true medical error. The post generated a lot of comments, most of which seemed to miss the point; as long as humans are involved in any endeavor, there will be errors.  Even if the humans are in control of a fully automated system, there will be errors (calibration, maintenance, supplies, etc.).  The goal of any process improvement should be to reduce the human errors committed, but unfortunately will never be completely eliminated.

Looking at things from a clinician’s point of view, not all reported medical “errors” are errors.  Some are merely complications of procedures. Upon further analysis, those original studies citing the number of lives to be saved by preventing those errors aren’t as many as they would have you believe.  They also falied to consider the health status of the patients before the error had occurred and whether or not that patient may have survived regardless of the error.

Medical errors are defined as: Errors or mistakes committed by health professionals which result in harm to the patient. They include errors in diagnosis (DIAGNOSTIC ERRORS), errors in the administration of drugs and other medications (MEDICATION ERRORS), errors in the performance of surgical procedures, in the use of other types of therapy, in the use of equipment, and in the interpretation of laboratory findings. Medical errors are differentiated from MALPRACTICE in that the former are regarded as honest mistakes or accidents while the latter is the result of negligence, reprehensible ignorance, or criminal intent. I don’t believe that any clinician would be accepting of medical errors, much less negligence.  I’m sure many errors occur daily and no one hears about them or even knows they have occurred because the patient was not harmed.  These errors are no more significant than any other.  We shouldn’t only focus on those errors that result in loss of life or a negative patient outcome.  If we improve the processes that lead up to those preventable errors then perhaps we can have a truly positive impact on patient outcomes.

Take for example the Medicare quality measure of a urinary tract infection. This is one of the diseases/conditions sited by Healthgrades as being of significant cost and related to loss of life amongst Medicare patients.  If a patient is admitted to the hospital and after two days is diagnosed with a urinary tract infection (UTI), the hospital is dinged by Medicare with a “preventable” infection and will not pay any costs related to that UTI, even if the patient is overcome by septic shock and spends days in the ICU.

Now take that same patient, but instead of admitting them directly, they have testing done at the time of admission showing they have the “possibility” of a UTI.  I, as the admitting physician, document they may have a UTI, and possible septicemia.  Two days later, they become ill and end up in the ICU.  Both scenarios can be the same patient.  The only difference is the documentation in the chart at time of admission.

Under no circumstances was the UTI in either case a “preventable” one,  but from Medicare’s standpoint, the first case is not their problem, financially.  They also consider that UTI to be a negative quality issue with a negative quality mark against that hospital, available for review on the internet.  Not a true, fair representation of that hospital or its staff.  Our hospital chose to screen all admissions for possible UTI with a urinalysis at the time of admission.  In that way we were able to “catch” those patients, who may have been asymptomatic, with a UTI at the time they were admitted.  Defensive medicine being practiced by a hospital, not a physician, because of Medicare’s misunderstanding of “preventable”.

Another hospital screened every patient for clostridium difficile colitis and MRSA at the time of admission.  And a very high number of patients were positive on their screening tests.  These are also quality measure conditions that Medicare deems as “preventable”.  If they are diagnosed after admission, Medicare classifies them as “hospital acquired” and gives the hospital a negative quality mark and may decrease their overall reimbursement for ALL Medicare patients.  Another example of increased costs of medicine due to Medicare’s demand for the prevention of diseases that aren’t preventable and placing the hospitals in a defensive position.  Their limited clinical understanding of disease processes has forced hospitals to order testing and perform screenings to show that many of the infections Medicare deems as preventable are actually present on admission.

As Medicare continues to reduce reimbursements I’m sure you will see more “defensive” medicine practiced by hospitals in an attempt to get a higher quality rating and therefore more reimbursement.  And, that doesn’t even scratch the surface of truly preventable diseases or medical errors.

Doc B

My opinion is free.

Advice is worth exactly what you pay for it.

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