Transcript Health Care Harm

Medical Errors:
Data on the
Invisible Epidemic
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Joe Graedon, MS, & Terry Graedon, PhD
OCHU/CUPE • 6/4/12
Imagine
3 of These Each Day
Deaths & Mortality • U.S.
CDC Data
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TOTAL U.S. DEATHS
Heart Disease
Cancer
Lower Resp. Dis.
Stroke
Accidents
Alzheimer’s
2,437,163
599,413
567,628
137,353
128,842
118,021
79,003
Data posted as of March, 2012
Health Care Harm
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Infections (HAIs)
Fatal ADEs (hosp)
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(Lazarou, JAMA, 1998)
Fatal ADEs (nursing)
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93,000
( Handler, Ann. Longterm Care, 2010)
Fatal ADEs (OP)
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> 100,000 (CDC)
106,000
198,815
(Bootman, Am. J. Health-Syst. Pharm., 1997)
Health Care Harm
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Lethal VTEs
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32,591
(Zhan, JAMA, 2003)
Excessive radiation
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12,000
(Starfield, JAMA, 2000)
Surgical complications
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Range: 100,000 to 300,000
(Raskob, Am. J. Prev. Med. 2010; Heit, Blood, 2005)
Unnecessary surgery
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119,000
29,500
(Berrington de Gonzalez Arch. Intern.Med., 2009)
Health Care Harm
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Pressure ulcers (bed sores)
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(Allman, N. Engl. J. Med. 1989)
Misdiagnosis
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60,000
132,500
Range: 40,000 to 225,000
(Newman-Toker, JAMA, 2009; Shojania, JAMA, 2003;
Wachter, Arch. Intern. Med., 2009)
TOTAL: 883,406
Common Diagnostic
Mistakes
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Blood Clot in Lungs or Legs
Adverse Drug Event
Cancer
Acute Coronary Syndrome
Stroke
Congestive Heart Failure
Canadian Data
“There is limited knowledge about the
incidence of adverse events and health
care error in Canadian health care,
and little knowledge about current
initiatives to improve patient safety.”
Baker & Norton, Patient Safety and Health Care
Error in the Canadian Health Care System.
Health Canada 2001
Health Care Harm
in Canada
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ADEs
32,921
(Canadian Adverse Reaction Newsletter, 2011)
May represent only 1 to 10% of actual ADEs
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Chart Review:
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11% had injuries resulting in death, disability, + hosp
20% of these events were lethal; 37% highly preventable
(Baker & Norton, CMAJ, 2004)
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Diagnostic Errors
15% of preventable deaths
(Croskerry, CMAJ, 2010)
Numbed by Numbers
“Statistics are people
with the tears
wiped away.”
Irving Selikoff, MD
Helen Graedon
Born
Died
September 27, 1904
December 14, 1996
• School teacher
• Civil rights advocate
• Peace activist & poster artist
• World citizen
Drug Interaction
Demerol-Selegiline interaction =
 serotonin syndrome
• Muscle spasms
• Emotional distress
• Nurse denied connection with drug
• Legs tied down
• Bar on side of bed down
• Attempt to walk--walker not close by
• Fall
• Death due to retroperitoneal bleeding
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Prescribers’ Knowledge
About Interactions
A Postal Survey of US Prescribers
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14 drug pairs sent in questionnaire
< 50% identified unsafe combos
Tagamet (cimetidine) & Coumadin
Conclusion: “knowledge poor”
“Alert Fatigue” > Computer Overrides
Drug Safety June, 2008
What caused this woman’s death?
Justice Ginsburg?
Questions to Ask about
your Prescription
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Other ways to treat this problem?
Evidence-based effectiveness?
Most common/serious side effects
Symptoms requiring action
How can I contact you?
How to take this medicine
How to stop this medicine
Reducing Misdiagnosis
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Teach back (verify my 1º concerns)
Confidence in diagnosis?
Other tests that might clarify Qs?
Symptoms that don’t fit!
What else could it be?
“Gimme my damned data!”
Follow-up plan & contact info
Avoiding Hospital Errors
Expect Mistakes!
Take an advocate!
Check every drug
Be assertive
In doubt? Say NO!
Condition H (Help!)
Hazardous handoffs
Communication & Teamwork
Prevents Problems
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We need better data!
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Mandatory reporting
Let patients (& families) help
Informed
 Respected
 Empowered
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