On July 17th, 2014 the Senate Subcommittee on Primary Health and Aging held an important hearing on “Over 1000 Deaths Per Day is Too Many: The Need to Improve Patient Safety“. Six experts testified and shared pdf. files of their reports including citations.
To download all of the experts’ complete testimonies or listen to the hearing go here.
To get links to all expert excerpts published in Confident Voices in Healthcare Blog go here.
Estimating Harm: By 2011 I had noticed four new studies that had used the Global Trigger Tool to identify adverse events in medical records. Two were peer- reviewed studies published in medical journals, and two were from the Office of the Inspector General. This tool was much more efficient at identifying adverse events than unguided physician reviews. I noted that the individual studies gave a remarkably consistent picture of the prevalence of lethal adverse events. In addition, other studies had been published showing that medical records often do not contain discoverable evidence of serious patient harm even when the patients know they were seriously harmed. In 2013 the Journal of Patient Safety published my study on the prevalence of preventable adverse events in hospitals. It has been supported by leading doctors in the patient safety community.
The math behind my calculation is rather simple. 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. This yields an estimate of 210,000; however, the trigger tool, while good at detecting errors of commission, misses many errors of omission, communication, context, and diagnosis. It would not have detected any of the catastrophic errors made by my son’s doctors. Furthermore, it misses events for which no evidence appears in the medical record. Correcting for these limitations yields an estimate that more than 400,000 lives are shortened by preventable adverse events each year.
To read my open letter to the Senate Subcommittee in response to the hearing go here.