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Our health system endangers patients
Are you worried and concerned that you will not obtain adequate care, that you need and you deserve? You could be right. With many regards or in some respects, the current health system is no longer what it was. However the majority among us continue, wrongly and at our expense, to trust this health system. You have an alternative: increase your knowledge, choose better doctors and treatment and take control of yourself. Nobody can take care of his health or that of his children as well as yourself. It is down to you to practise a healthy life style, educate yourself about health problems which you have, insist on obtaining diligent and effective care.
How did it used to be?
The doctors decided what was best for their patients health. There were just enough doctors who worked hard and acquired by the practice a great deal of experience. Their nurses respected them and their nurses were good and efficient care providers. Health insurance refunded to patient the physician fees. The patient relied on his doctor and his insurance. Physicians practised and made decisions for their patients good.
How does it currently work?
Our health system has completely changed: physicians, who made therapeutic decisions for you, have increasingly hands tied. Many doctors became public hospitals employees and medical insurance plans, Health Maintenance Organization (HMO) employees, made decisions for them, and thus for you. The patient is increasingly the hostage of public health, insurance and too many doctors, who are, not any more, the patients defenders. Insurances and authorities use, more and more, coercive, unjust and fraudulent processes, with the aim of controlling the relation between doctors and patients, so as to withdraw from them profits, to the detriment of both patients and doctors.
When doctors no longer have the the right to make decisions for and with the patient, but that they do it for insurance companies or hospital administrators, it is sooner or lateer the patient who pays for it with his health, or even his life. In fact, the doctor must have and can have only one owner: patients, because no one can serve two masters at the same time, especially not a doctor! Currently more and more life and death decisions depend on financial interests. It is thus today up to the patient to stand up for themselves, against a refusal, a delay, a primary care physician which does not want to send the patient to a specialist doctor, against care lower than average standards. In this situation, more the patient knows, the better he is protected and the better he is treated.
Many doctors, especially in the public sector and HMO, do not practise any more and do not take any more decisions for patients. They do it for insurance, HMO or their employer. The patients become more and more the hostages of the cheaper doctors, their insurance or public hospitals. In large public hospitals , there are more and more doctors who do even things on the patients. They find their satisfaction, not in looking after patients, but making publications and posters after having do things on patients. They do not behave any more like doctors, but like sorcerer's apprentices.
And that will become worse, since, with the example from what occurred in other countries, swiss patients will realize, at their expense, that doctors have also the capacity to do nothing. These doctors have, more and more often the nurses whom they deserve. Nurses are more and more badly selected, badly trained, inefficient and bad nursing staff. Having acquired during their nursing school the worship of pauses, reports, conferences, red and blue pencil and bureaucratic patient file, many became lazy, moaners, and dangerous for patients. On one hand, they reduce patients to the level of two-years-old and became followers of half done work, and on the other, they do not follow the doctors orders and take bad personal initiatives. When they do not prescribe drugs and so on... in the place of the doctors!
The majority of patients go to a doctor or enter to an hospital believing that they will be treated there by qualified and experiences, proven professionals, and that they will undergo only the necessary examinations and treatment, so that the outcome, for them, will be a success. Reality however is different: some of these professionals are inefficient, irresponsible, drug addicts, alcoholic, do not supervise doctors in training, and are hidden, as well their errors, as the discriminatory rationing which is practised more and more in public hospitals. Some wards suffer already from a culture of negligence of one's duties/reponsibilities. We cannot continue to waste our health because of insurers cupidity and incompetence of too many medical and administrative persons in charge. Soon, only political leaders, and poor mediocre heads of mediocre public hospitals, will repeat that public health in Switzerland is the best in the world, that is to say precisely those who do all to worsen public health.
You thus need today PatientProtect.com. Because, to stop the existing problems, it is first of all necessary to admit that they exist, therefore being informed, then to complain effectively. PatientProtect.com helps you to inform you better, to defend you, if necessary to complain for you, indeed to protect you. Do not hesitate to contact this doctor by e-mail: patientprotect@bluewin.ch.
Quality, safety, errors and adverse events, health care and technological medicine are not as sure as it would have and could be. It is manifest that medical errors are a principal cause of death and damage, therefore also of a serious lack of quality. Although much is to be learned about the types of medical erros/accidents, and on why they occur, today, one knows sufficiently to recognize that there is a matter which enough seriously worries patients.
Safety, the first field of quality, refers to accidental damage absence. This definition is stated from the patient point of view. Generally, safety is a characteristic of a system and not of system components. Safety is a property being born from systems. So that this property is present, health organizations must develop a system orientation towards patient safety, rather than an orientation which seeks to blame the individual.
The second field of quality refers to supply of care in conformity with current medical knowledge and a practice of top quality medicine. Currently the practice of medicine is extremely variable. Often, one notes a lack of adherence to medical standards based on scientific evidence. When somebody needs medical care, worst quality is not any care of the whole.
An error is defined either like failure to realize, as envisaged, a planned action (i.e., error of execution), or like use of an erroneous plan to achieve a goal (i.e., error of planning). One knows much better errors which occur in hospital environment than those which occur in other fields of health. With the exception of complications associated with drugs, mentioned further, very few research concentrated on adverse errors or events occurring apart from the hospital environment, for example in ambulatory care services, surgical ambulatory services, doctor's surgery, nursing homes, home care, and managed by the patients, their families or their close relations at home.
An adverse event is a damage resulting from a medical intervention, or in other words, it is an unfavourable event which is not due to the patient condition, but caused by medical care and treatment.
An adverse event ascribable to an error is an avoidable adverse event. Adverse events by negligence represent a subset of avoidable adverse events, which satisfy legal criteria used to determine if there were negligence. I.e. if provided care does not reach the level of care which one reasonably awaits from an average doctor qualified to deal with the patient in question.
Data of the medical literature
You cannot believe it. Then know that medical literature data suggests that:
One quarter of deaths occurring in hospitals can be prevented (Dubois and al. 1988).
A third of surgery and procedures applied in hospital expose patients to unnecessary risk (Brooke and al. 1990).
A third of drugs given to patients are not medically advisable (Brooke and al. 1990).
A third of laboratory tests abnormal results is not taken into account by doctors (Brooke and al. 1990).
Medical files monitored of in-patients highlight an alarming errors incidence, with half of errors occurring in surgical services (Leapen and al. 1991, Gavande et al.. 1999).
On top of these observations, there are to be added, that many practised surgery are not adapted, or not even medically advisable (Chassin 1987, Berstein 1993, Phelps 1993, Kassires 1993, Caplan 1991 and Redelmeir 1990).
In England, each year, after cancer (156.000 deaths) and cardiac affections (140.000 deaths), medical error is the third most frequent death cause.
In England, medical errors kill 40.000 patients each year. It is approximately four times more than all other types of accidents.
Additionally, in British hospitals, each year, 280.000 patients suffer from drugs prescription errors, drugs overdoses and hospital acquired infections.
These patients must, because of these incidents, remain hospitalized on average for six additional days. This is extremely expensive. As always, the consequence is an insurance premiums or tax increase for all patients.
The true tragedy of current hospital medicine, is that there are many errors, in particular in hospitals, these errors repeat themself because they are not, often still, even indexed, that they are not analyzed, and because one does not seek to eliminate them systematically. However anesthesiologists have, them, makes the proof that a doctor could, in a hospital environment, learn from his errors.This progress was obtained thanks to a systematic approach aiming at reducing the errors count, that in a cultural environment where it became natural and without risk to submit his errors, to call in question the system, to change the system and to work about true adverse events causes. Safety is, therefore, in hospitals too, a business of entreprise culture.
Let us see more details concerning some recent studies.
The broadest study about adverse events is that called Harvard Medical Practice Study, a medical practice study of more than 30.000 patients at their exit of hospital, exits selected by chance in 51 hospitals chosen by chance in New York State (Brennman and Al 1991). Adverse events characterized by hospitalisation prolongation, or infirmity at the time of hospital exit, occurred in 3.7 percent of hospitalizations. The adverse events proportion due to errors (i.e., avoidable adverse events) was 58 percent. The adverse events due to negligence proportion was 27.6 percent. Although the majority of these adverse events caused a disability lasting less than 6 months, 13.6 percent of these adverse events were at patients death origin and 2,6 percent caused permanent invalidating damage. Most frequent complications were due to drugs (19 percent), followed by wounds infections (14 percent) and technical complications (13 percent).
The results of Medical Practice of Harvard Study in New York were recently corroborated by a study from 1992 of adverse events in Colorado and Utah, (Thomas et al., 2000). This study examined medical files of a random sample of 15.000 patients at their hospital exit, of a hospital representative sample in these two states. Adverse events occurred in 2,9 percent of hospitalizations in each state. Approximately four of five of these adverse events occurred during patients hospital stay, and the others occurred before hospital admission, in doctors offices, in patients home or in any other place apart from hospitals. The avoidable adverse events due to negligence proportion was 29,2 percent. The avoidable adverse events proportion was 53 percent. Just as in New York study, more than 50 percent of adverse events were represented by minor and transitory lesions. But in New York the study highlighted that 13,6 percent of adverse events led to death, compared to 6,6 percent in Colorado and Utah. In New York, approximately one in four adverse events by negligence led to death, whereas in Colorado and Utah, death was the consequence of approximately one adverse event by negligence on 11. The factors which could explain the difference between the two studies include: change in time of population health, differences between states populations and health systems.
The New York study and the Colorado and Utah study identified a subset of avoidable adverse events which satisfy the criteria applied by courts to determine if there were negligence. It is important to note that some of these cases could be caused to people receiving care and treatment by incompetent or physicaly or psychicaly decreased health professionals. PatientProtect.com estimates that many of these adverse events could have probably been avoided, if better care systems had been set up. The extrapolation of Colorado and Utah results, applied to more than 33,6 millions hospital admissions of the United States in 1997, implies that at least 44,000 Americans die in hospitals each year, because of avoidable medical errors (Thomas et al., 1999 and 2000). If one bases oneself on the New York study, annual number of deaths due to medical error can reach 98,000. In any event, even the lowest evaluation represents a figure higher than the number of deaths ascribable to the eighth cause of mortality in the USA.
Two studies based on medical files examination and other sources of information, such as health professionals reports, highlighted even higher rates of adverse events occurring in hospitals. Thus for example, in a study of 815 consecutive patients in a general medicine service of teaching hospitals, one noted that 36 percent of these patients suffered from an iatrogenic affection, defined as a disease which resulted from a diagnostic procedure, or any form of treatment concerning the affection from which the patient (Steel et al., 1981) suffered at first. Of these 815 patients, nine percent had a iatrogenic disease which threatened their life, or caused a very significant disability, and for two more other percent, the iatrogenic affection contributed to patient death.
In a study of 1,047 patients admitted in two intensive care services and one surgical unit of a large teaching hospital, 480 patients (45,8 percent) suffered from an adverse event. In this last study, an adverse event was defined as a situation in which an inadequate decision was made, whereas a suitable alternative could have been selected (Andrews and al. 1997). For 185 of these patients (17.7 percent), the adverse event was serious, producing disability or death. The probability of being a victim of an adverse event increased approximately six percent for each day of hospitalization. A reason more to leave the hospital as quickly as possible!
An analysis in 1991 concerning 203 heart failure incidents in teaching hospitals, highlighted that 14 percent of these heart failures were due to iatrogenic complications, and that more than half of the latter could have been avoided. In a study of 44.603 patients operated between 1977 and 1990 in a great hospital complex, 2.428 patients (5,4 percent) suffered from complications. Almost half of these complications were due to medical errors (McGuire and al. 1992). 749 of these patients died during their hospitalization. 7.5 percent of these deaths were due to errors.
The contribution of complexity and technology to such error rates is illustrated by the higher rates of adverse events observed in highly technical surgical specialities such as vascular surgery, cardiac surgery and neurosurgery. In hospitals, high rates of errors with serious consequences are found above all in intensive care service, operating rooms and emergency room.
The drugs can be dangerous too
The errors involving drugs account for one death out of 135 ambulatory patients deaths, and one death out of 854 in-patients deaths. The drugs errors frequently occur in hospitals. All these errors do not end in damage, but the damage which result from these errors are expensive.
A recent study, done in two prestigious teaching hospitals, found that almost two percent of admissions suffered from an avoidable adverse event due to the medicinal treatment, having for result an increase in hospital costs by case on average of 4700 dollars, or approximately 2,8 million dollars annually for a 700 beds teaching hospital (Phillips 1998). If these results are generalizable, the only hospital costs of avoidable adverse events due to medicamentous treatments of in-patients rise annually in the USA to several billions dollars per year.
In-patients represent only a fraction of the total population which is likely to suffer from a drug adverse event. In 1998, in the USA, nearly 2.5 billions drugs prescriptions were prepared by pharmacies, that at a cost of 92 billions dollars. Many studies document drugs prescriptions errors (NWDA 1998, Hallas and al. 1990), in the preparation of these prescriptions by the pharmacists, (Willcox and al.1994), and due to patients involuntary non-compliance (Einarson and al. 1993). Drugs errors have a strong potential to increase avoidable morbidity and mortality, since new drugs are introduced for a broader spectrum of symptoms. By examining death certificates in the USA between 1983 and 1993, one found that 7.391 people hospitalized in 1993 died of medicamentous errors (accidental poisoning by biological drugs or other substances following errors recognized by patients or medical personnel), whereas only 2.876 hospitalized people had died in 1983. This difference over 10 years represent an increase of .2.57 times (Phillips, 1998).
Concerning ambulatory patients, the situation was worse since the deferred deaths due to medicinal errors increased 8.48 times on this ten years period. The children are particularly at risk with regard to drugs errors, the principal error being dosage error (Koren and al. l994, Perlstein and al. 1979).
Do not believe that drugs errors are due only to physicians and nurses. Pharmacists do much of it. It is well-known that errors also occur in prescriptions preparation by pharmacists. According to a recent study with regard to Massachusetts pharmacists in the USA (State Board of Registration in Pharmacy), each year 2,4 million prescriptions are prepared there incorrectly for about 6 millions inhabitants (Knox and al. 1999). 88 percent of these pharmacists errors consisted in giving patients, either the wrong drug, or the wrong posology. Generally, it was estimated that, for each dollar spent in drugs in ambulatory surounding, another dollar is spent to deal with new health problems caused by drugs (AAR, 1998). A study of 1994 concludes that, in the USA, each year, health costs concerning morbidity and mortality allotted to drugs reached 76,6 billions dollars. (Johnson 1995).
Errors relating to drugs are thus very frequent. The majority really do not harm health, but those which do, are very expensive. A recent study, done in two prestigious hospitals, found that almost 2 percent of patients admitted in these hospitals suffer from an avoidable drug adverse event, resulting in an average hospitalstay of 4.6 days and a greater average hospital stay cost of 4.700 dollars (Bates 1995). This, annually, represents approximately 2,8 millions dollars for a 700 beds teaching hospital. If these results are generalizable, the only costs of avoidable adverse events due to drugs represent approximately 2 billions dollars, year in year out, in the USA. Drugs errors also occur in nursing homes. For each dollar spent in drugs, one spends there 1,33 dollars for treatment of morbidity and mortality related to these drugs. On the whole, that represents, by year, 7,6 billions dollars for the USA. Bootman et al. in 1999, estimated that 3,6 of this 7,6 billions could be saved by decreasing avoidable drugs adverse events.
Active errors, latent defects and systems
By considering how the human ones make errors, it is important to distinguish active errors from latent errors. Active error occurs on operator level, on the contact line, and its effects are felt almost immediately. This is why one speaks sometimes about first line errors. Latent errors, they, tend being eliminated from operator direct control and include things such as bad design, inadequate installation, defective equipment maintenance, bad management decisions, and especially badly structured and/or badly managed organizations. To these, one often adds experience and formation shortcomings. Latent errors constitute the safety greatest threat in a complex system as a large public teaching hospital, because they are often not recognized and have the capacity to have, as consequences, multiple active errors .
A system is a whole of interdependent elements acting the ones on the others, to carry out a common objective. Elements can be humans (administrators, physicians, nurses etc...) and not-human (equipment, technologies, etc...). A system is a whole of elements, processes, and of relations which bind them to obtain a result. Any system is organized in four coordinated hierarchical levels: units, parts, subsystems, and systems. When great systems are put in failure, (for example, in a large hospital, false leg amputation of a patient, or uterus ablation of false patient), that is due to multiple latent defects which appear together in an unforeseen interaction, creating a series of events in which the defects grow and develop. Their accumulation result in an accident. An accident is an event which implies damage with a defined system, which disturb the course of things, or future result of this system. Individually, no single factor caused the accident, but when several factors appear together, the disaster strikes. Perrow, (1984), used framework DEPOSE, (Design, Equipement, Procedures, Operators, Supply, and Environment), to identify potential sources of system failure. By evaluating environment, some researchers explicitly include design and oranization characteristics.
Thus, for example, the analysis of Challenger accident highlighted latent defects and events having contributed over the nine previous years. The people working in the system can have sorrow to pay their attention on these latents errors or defects. Indeed generally, these errors are hidden in routine procedures design, in structure, or in organization management . In addition people are accustomed to these latent defects and learn how to work in this milieu. Which makes that these defects are often even not identified. In his book on Challenger explosion, Vaughan, in 1996, described this deviance standardization, in which small behaviour changes become the standard and draw aside the limits; so much so that additional deviations are regarded as acceptable. When deviating events become acceptable, the potential for errors is created, because the signals, being not taken into account or misinterpreted, accumulate without even being noticed. To concentrate on active errors lets latent defects remain in the system, and their accumulation makes really the system more inclined to future failures. To discover latent defects, correct them and decrease their extent, are likely to have a greater effect to make systems safer than efforts to reduce to a minimum active errors in the place where they occur.
The characteristics of strongly reliable industries, like should be all hospitals, include an organization which put a lot of time and effort into safety, high level of personnel crossschecking, security measures, and has a strong organization culture, putting the priority on knowledge, change and safety.
Safety is defined like absence of accidental damages. This simple definition identifies that, according to patient perspective, the safety first objective is to prevent and stop accidental damage.
Generally, health is a complex and narrowly coupled system. The activities in an emergency ward, operating rooms, or an intensive care unit are complex and narrowly coupled systems examples.
If an environment is safe, risks of accidents are less. Postulate is that system approach can improve much and durably safety in every enterprise. In a hospital, to make an environment safer means to examine processes of care, to reduce latent defects in these processes, or deviations in the way in which things should be made. To ensure patient safety, thus implies creation of systems and operational processes which increase patient care reliability.
Anesthesiology
Although many people believe the opposite, health professionals get very little involved into patient safety. There were only very few collective actions. The most often quoted exception is the work which was carried out in particular by american, australian, and swiss anesthesiologists to improve safety and outcome for their patients. In anesthesiology, death rate allotted to general anaesthesia, which was, before the Second World War of 1 death for 50 anaesthesias and in the seventies, from 1 to 2 per 10.000 general anaesthesias, fell to approximately 1 per 200.000 for patients having only little or no risk factors, and to 1 per 20.000 anaesthesias if one takes account of all risk patients and all anaesthetic acts and processes. Anaesthesia current risk is thus comparable with that of one year automobile driving. Progress in anesthesiology is thus impressive. Nevertheless, anesthesiology must still make much progress, to reach the level of civil aviation risk, that is to say of one accident for eight million flights. This success was obtained thanks to a combination of:
Technological changes (new monitoring equipment, standardization and generalization of existing equipment).
Information based strategies, including development and generalized adoption of directives of good clinical practice and standards.
Knowledge application of human elements to improve performances, such as for example teaching simulators.
Creation of patients safety foundations, in order to gather all people taking part of various horizons (doctors, nurses, manufacturers etc...) and to create an action center.
Systematic approaches to collect adverse incidents and events, to analyze them and correct errors.
To have leaders who were the champions of the cause.
Who is responsible for all these medical errors?
The individual or the system? The people majority regards medical errors as a care provider individual problem, rather than as a failure in the process to provide care in a complex system. When one ask them on the possible solutions to prevent medical errors, measures to be taken evaluated as very effective are: to prevent the professionals of health who had problems to practise (75 %), and better professionals health training (69 %) (NPSF, 1997). The usual initial reaction, when an error occurs, is to find and blame somebody. However even apparently single adverse events are generally due to multiple factors convergence. To blame an individual does not change these factors and the same error is extremely likely to reproduce!
To prevent errors and improve patients safety requires a systemic approach in order to modify the system conditions which contribute to errors. Professionals working in health, such as doctors and specialized nurses, are still, among the most educated and conscientious of labour world. The problem, usually, is not bad professionals, but bad leaders and a system needing to be made safer. Postulate is that, in every enterprise, system approach can improve much and durably safety.
What does one have to do?
The errors in the health industry are at an unacceptable high level. Physicians and industry efforts were dedicated too much on innovations without an equal and parallel effort relating to patient safety. As for civil and military aviation, national engagement to raise safety level is necessary. This will require strong doctors leadership, to specify objectives and mechanisms to control progress, and suitable knowledge base. Financing of suchl should be included in health budget and grow gradually to reach roughly 1 % of the hundreds of millions which cost adverse events and avoidable incidents. It is modest in comparison with other health problems. PatientProtect.com is convinced that a reduction in at least 5% of errors over five years is imperative and urgent, for many patients and the taxpayers own good.
One must recognize, however, that some individuals can be inefficient, incompetent, unqualified, physically/mentaly a lot weaker, negligent, or bad nursing staff, or even have criminal intentions. The public requires to be sure that such individuals will be dealt with effectively, and prevented from harming to patients. Professionals teams, known as " tiger teams ", are employed to examine vulnerability of companies systems, in particular that with hackers. The idea to employ teams, with sophisticaded technical systems knowledge, to test them and anticipate the ways in which health systems can badly function, should be adopted by official health organizations.