08:35 PM ET 11/29/99

Report Cites Deadly Medical Errors

 Report Cites Deadly Medical Errors
 AP Medical Writer=
           WASHINGTON (AP) _ Medical mistakes kill anywhere from 44,000 to
 98,000 hospitalized Americans a year, says a new report that calls
 the errors stunning and demands major changes in the nation's
 health care system to protect patients.
           The groundbreaking report by the Institute of Medicine says
 there are ways to prevent many of the mistakes and sets as a
 minimum goal a 50 percent reduction in medical errors within five
           The problem is less a case of recklessness by individual doctors
 or nurses than it is the result of basic flaws in the way
 hospitals, clinics and pharmacies operate, the report says. The
 institute cited two studies that estimate hospital errors cost at
 least 44,000, and perhaps as many as 98,000, lives, but research on
 the topic is unable to pinpoint fatalities more precisely.
           Doctors' notoriously poor handwriting too often leaves
 pharmacists squinting at tiny paper prescriptions. Did the doctor
 order 10 milligrams or 10 micrograms? Does the prescription call
 for the hormone replacement Premarin or the antibiotic Primaxin?
           Too many drug names sound alike, causing confusion for doctor,
 nurse, pharmacist and patient alike. Consider the painkiller
 Celebrex and the anti-seizure drug Cerebyx, or Narcan, which treats
 morphine overdoses, and Norcuron, which can paralyze breathing
           Medical knowledge grows so rapidly that it is difficult for
 health care workers to keep up with the latest treatment or newly
 discovered danger. Technology poses a hazard when device models
 change from year to year or model to model, leaving doctors
 fumbling for the right switch.
           And most health professionals do not have their competence
 regularly retested after they are licensed to practice, the report
           Indeed, health care is a decade or more behind other high-risk
 industries in improving safety, the report said. It pointed to the
 transportation industry as a model: Just as engineers designed cars
 so they cannot start in reverse and airlines limit pilots' flying
 time so they're rested and alert, so can health care be improved.
           ``These stunningly high rates of medical errors ... are simply
 unacceptable in a medical system that promises first to 'do no
 harm,''' wrote William Richardson, president of the W.K. Kellogg
 Foundation and chairman of the institute panel that compiled the
           As the report's title _ ``To err is human'' _ implies, no one
 will ever eradicate medical mistakes.
           But ``errors can be prevented by designing systems that make it
 hard for people to do the wrong thing and easy for people to do the
 right thing,'' Richardson concluded. Unfortunately, he continued,
 medical mistakes usually are ``discussed only behind closed
           In recent years, however, researchers have begun coming up with
 ways to avert medical mistakes. Some hospitals now use computerized
 prescriptions, avoiding the handwriting problem and using software
 that warns if a particular patient should not use the prescribed
 drug. Many hospitals now mark patients' arms or legs _ while
 they're awake and watching _ to prevent removal of the wrong limb.
 Anesthesiologists made their field safer by getting manufacturers
 to standardize anesthesia equipment from one model to the next. The
 Food and Drug Administration is trying to prevent new drugs from
 hitting the market with sound-alike names.
           But the Institute of Medicine concluded that reducing medical
 mistakes requires a bigger commitment, and recommended some
 immediate steps:
           _Establish a federal Center for Patient Safety in the Department
 of Health and Human Services. Congress would have to spend some $35
 million to set it up, and it should eventually spend $100 million a
 year in safety research, even building prototypes of safety
 systems. Still, that represents just a fraction of the estimated
 $8.8 billion spent each year as a result of medical mistakes, the
 report calculated.
           _The government should require that hospitals, and eventually
 other health organizations, report all serious mistakes to state
 agencies so experts can detect patterns of problems and take
 action. About 20 states now require such reports, but how much
 information they require and what penalties they impose for errors
 varies widely, the report said.
           _State licensing boards and medical accreditors should
 periodically re-examine health practitioners for competence and
 knowledge of safety practices.
           ``Any error that causes harm to a patient is one error too
 many,'' said Dr. Nancy Dickey, past president of the American
 Medical Association, which already has started a National Patient
 Safety Foundation designed to address some of these issues.
           But she cautioned that some of the changes will be difficult
 because doctors do face large liability for any mistake. ``We may
 know to talk about a culture of safety, but we still live in an
 environment of blame,'' she said.
           The Institute of Medicine is part of the National Academy of
 Sciences, a private organization chartered by Congress to advise
 the government on scientific matters.