medical errors: data on the invisible epidemic joe graedon, ms, & terry graedon, phd joe...

Medical Errors: Medical Errors: Data on the Data on the

Invisible EpidemicInvisible Epidemic

Joe Graedon, MS, & Terry Graedon, PhDJoe Graedon, MS, & Terry Graedon, PhD

OCHU/CUPE • 6/4/12

Imagine Imagine

3 of These Each Day 3 of These Each Day

Deaths & Mortality • U.S.Deaths & Mortality • U.S.CDC DataCDC Data

TOTAL U.S. DEATHS TOTAL U.S. DEATHS 2,437,1632,437,163 Heart Disease Heart Disease 599,413599,413 CancerCancer 567,628567,628 Lower Resp. Dis.Lower Resp. Dis. 137,353137,353 Stroke Stroke 128,842 128,842 Accidents Accidents 118,021118,021 Alzheimer’sAlzheimer’s 79,003 79,003

Data posted as of March, 2012

Health Care HarmHealth Care Harm

Infections (HAIs)Infections (HAIs) > > 100,000100,000 (CDC) (CDC) Fatal ADEs (hosp)Fatal ADEs (hosp) 106,000106,000

(Lazarou, (Lazarou, JAMA, 1998JAMA, 1998)) Fatal ADEs (nursing)Fatal ADEs (nursing) 93,00093,000

(( Handler, Handler, Ann. Longterm CareAnn. Longterm Care, 2010), 2010) Fatal ADEs (OP)Fatal ADEs (OP) 198,815198,815

(Bootman, (Bootman, Am. J. Health-Syst. Pharm.Am. J. Health-Syst. Pharm., 1997), 1997)

Health Care HarmHealth Care Harm

Lethal VTEsLethal VTEs 119,000119,000 Range: 100,000 to 300,000Range: 100,000 to 300,000 (Raskob(Raskob, Am. J. Prev. Med. , Am. J. Prev. Med. 2010; Heit, 2010; Heit, BloodBlood, 2005), 2005)

Unnecessary surgery Unnecessary surgery 12,00012,000 (Starfield, (Starfield, JAMAJAMA, 2000), 2000)

Surgical complicationsSurgical complications 32,59132,591 (Zhan, (Zhan, JAMAJAMA, 2003), 2003)

Excessive radiationExcessive radiation 29,50029,500 (Berrington de Gonzalez (Berrington de Gonzalez Arch. Intern.Med., 2009Arch. Intern.Med., 2009))

Health Care HarmHealth Care Harm

Pressure ulcers (bed sores)Pressure ulcers (bed sores) 60,00060,000 (Allman, (Allman, N. Engl. J. Med. N. Engl. J. Med. 1989)1989)

MisdiagnosisMisdiagnosis 132,500132,500 Range: 40,000 to 225,000Range: 40,000 to 225,000 (Newman-Toker, (Newman-Toker, JAMAJAMA, 2009; Shojania, , 2009; Shojania, JAMAJAMA, 2003;, 2003; Wachter, Wachter, Arch. Intern. MedArch. Intern. Med., 2009)., 2009)

TOTAL: 883,406

Common Diagnostic Common Diagnostic MistakesMistakes

Blood Clot in Lungs or LegsBlood Clot in Lungs or Legs Adverse Drug EventAdverse Drug Event CancerCancer Acute Coronary SyndromeAcute Coronary Syndrome StrokeStroke Congestive Heart FailureCongestive Heart Failure

Canadian DataCanadian 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 HarmHealth Care Harmin Canadain Canada

ADEsADEs 32,92132,921 ((Canadian Adverse Reaction NewsletterCanadian Adverse Reaction Newsletter, 2011), 2011)May represent only 1 to 10% of actual ADEsMay represent only 1 to 10% of actual ADEs

Chart Review: Chart Review: 11% had injuries resulting in death, disability, + hosp11% had injuries resulting in death, disability, + hosp

20% of these events were lethal; 37% highly preventable20% of these events were lethal; 37% highly preventable(Baker & Norton, (Baker & Norton, CMAJCMAJ, 2004), 2004)

Diagnostic ErrorsDiagnostic Errors15% of preventable deaths 15% of preventable deaths (Croskerry, (Croskerry, CMAJCMAJ, 2010), 2010)

Numbed by NumbersNumbed by Numbers

“Statistics are people with the tears wiped away.”

Irving Selikoff, MD

Helen GraedonHelen Graedon

Born September 27, 1904Died December 14, 1996

• School teacher• Civil rights advocate• Peace activist & poster artist • World citizen

Drug Interaction Drug Interaction Demerol-Selegiline interaction =Demerol-Selegiline interaction = serotonin syndromeserotonin syndrome• • Muscle spasmsMuscle spasms• • Emotional distress Emotional distress • • Nurse denied connection with drugNurse denied connection with drug• • Legs tied downLegs tied down• • Bar on side of bed downBar on side of bed down• • Attempt to walk--walker not close byAttempt to walk--walker not close by• • FallFall• • Death due to retroperitoneal bleedingDeath due to retroperitoneal bleeding

PrescribersPrescribers’’ Knowledge Knowledge About InteractionsAbout Interactions

14 drug pairs sent in questionnaire14 drug pairs sent in questionnaire < 50% identified unsafe combos< 50% identified unsafe combos Tagamet (cimetidine) & CoumadinTagamet (cimetidine) & Coumadin Conclusion: Conclusion: ““knowledge poorknowledge poor”” ““Alert Fatigue” > Computer Overrides Alert Fatigue” > Computer Overrides

14 drug pairs sent in questionnaire14 drug pairs sent in questionnaire < 50% identified unsafe combos< 50% identified unsafe combos Tagamet (cimetidine) & CoumadinTagamet (cimetidine) & Coumadin Conclusion: Conclusion: ““knowledge poorknowledge poor”” ““Alert Fatigue” > Computer Overrides Alert Fatigue” > Computer Overrides

Drug Safety June, 2008

A Postal Survey of US Prescribers

What caused this woman’s death?

Justice Ginsburg?

Questions to Ask about Questions to Ask about your Prescriptionyour Prescription

Other ways to treat this problem?Other ways to treat this problem? Evidence-based effectiveness?Evidence-based effectiveness? Most common/serious side effectsMost common/serious side effects Symptoms requiring actionSymptoms requiring action How can I contact you?How can I contact you? How to take this medicineHow to take this medicine How to stop this medicineHow to stop this medicine

Other ways to treat this problem?Other ways to treat this problem? Evidence-based effectiveness?Evidence-based effectiveness? Most common/serious side effectsMost common/serious side effects Symptoms requiring actionSymptoms requiring action How can I contact you?How can I contact you? How to take this medicineHow to take this medicine How to stop this medicineHow to stop this medicine

Reducing MisdiagnosisReducing Misdiagnosis

Teach back (verify my 1º concerns)Teach back (verify my 1º concerns) Confidence in diagnosis?Confidence in diagnosis? Other tests that might clarify Qs?Other tests that might clarify Qs? Symptoms that don’t fit!Symptoms that don’t fit! What else could it be?What else could it be? ““Gimme my damned data!”Gimme my damned data!” Follow-up plan & contact infoFollow-up plan & contact info

Teach back (verify my 1º concerns)Teach back (verify my 1º concerns) Confidence in diagnosis?Confidence in diagnosis? Other tests that might clarify Qs?Other tests that might clarify Qs? Symptoms that don’t fit!Symptoms that don’t fit! What else could it be?What else could it be? ““Gimme my damned data!”Gimme my damned data!” Follow-up plan & contact infoFollow-up plan & contact info

Take an advocate!Take an advocate!Check every drugCheck every drugBe assertiveBe assertiveIn doubt? Say NO!In doubt? Say NO!Condition H (Help!) Condition H (Help!) Hazardous handoffs Hazardous handoffs

Avoiding Hospital ErrorsAvoiding Hospital Errors

Expect Mistakes!

Communication & Teamwork Communication & Teamwork Prevents ProblemsPrevents Problems

We need better data!We need better data! Mandatory reportingMandatory reporting

Let patients (& families) helpLet patients (& families) help InformedInformed RespectedRespected EmpoweredEmpowered