Re: [USMA:37973] Medical errorsPat,
I think that if you had written "10,000 babies die a year in the United States
due to medical errors", I would not have responded.
Regards
Martin
----- Original Message -----
From: Pat Naughtin
To: U.S. Metric Association
Sent: Sunday, February 18, 2007 12:24 AM
Subject: [USMA:37990] Re: Medical errors
On 2007 02 16 10:23 AM, "Martin Vlietstra" <[EMAIL PROTECTED]> wrote:
Which 10,000 babies die a year due to medical errors.
Since Pat wrote it, I will start with Australia. Population = 20,000,000.
Assuming that on average people make the biblical three score and ten years
implies that there are just under 300,000 births a year. If 10,000 babies die
a year due to medical errors, this means that one baby in 30 in Australia dies
due to medical errors.
If Pat was writing about the USA (population 300,000,000), then, using the
same logic, one baby in 450 would die per year due to medical errors.
Dear Martin,
Thanks for your calculations. They place severe stress on the estimation of
10 000 babies a year.
Either I got it wrong or the reporter got it wrong. I will investigate this
further.
In the meantime, my researches into medical errors generally show drastic
levels of error but usually only hospital errors are reported.
Let me quote from the Food and Drug Administration Report:
Make No Mistake: Medical Errors Can Be Deadly Serious
You will find this at: http://www.fda.gov/fdac/features/2000/500_err.html
In its report, To Err Is Human: Building a Safer Health System, the IOM
estimates that 44,000 to 98,000 Americans die each year not from the medical
conditions they checked in with, but from preventable medical errors. [IOM is
the National Academy of Sciences' Institute of Medicine]
.
The statistics in the IOM report, which were based on two large studies,
suggest that medical errors are the eighth leading cause of death among
Americans, with error-caused deaths each year in hospitals alone exceeding
those from motor vehicle accidents (43,458), breast cancer (42,297), or AIDS
(16,516).
But the numbers in the report don't tell the whole story, its authors
acknowledge. People in the hospital are just a small proportion of those at
risk. Doctors' offices, clinics, and outpatient surgical centers treat
thousands of patients each day; retail pharmacies fill countless prescriptions;
and nursing homes and other institutional settings serve vulnerable patient
populations.
In the report 'Medication Errors' at:
http://www.fda.gov/cder/drug/MedErrors/default.htm they say that:
The American Hospital Association lists the following as some common types of
medication errors:
a.. incomplete patient information (not knowing about patients' allergies,
other medicines they are taking, previous diagnoses, and lab results, for
example);
b.. unavailable drug information (such as lack of up-to-date warnings);
c.. miscommunication of drug orders, which can involve poor handwriting,
confusion between drugs with similar names, misuse of zeroes and decimal
points, confusion of metric and other dosing units, and inappropriate
abbreviations;
d.. lack of appropriate labeling as a drug is prepared and repackaged into
smaller units; and
e.. environmental factors, such as lighting, heat, noise, and
interruptions, that can distract health professionals from their medical tasks.
It seems to me that of these five dot points, the first four of them are
directly or indirectly related to measurements of some kind. It seems
reasonable to me to believe that about half of all medical errors are
associated with measurement errors.
Your estimate based on the Australian population:
'If 10,000 babies die a year due to medical errors, this means that one
baby in 30 in Australia dies due to medical errors.'
may not stand up to examination but your estimate of one error in 30 babies
is right in the ball park for medical errors generally, which tend to be
reported as about 3.7 % (see: Harvard Medical Practice Study) or 1 in 27 that
is close to your estimated error rate (but not death rate) of 1 in 30. Maybe
this is the source of my original error.
As I said, I will investigate this further, but I am not looking forward to
trying to carry out rational research in the land of smoke and mirrors called
medical statistics. Not least among the problems is the fact that medical
errors go by many names such as: clinical errors, iatrogenesis, medication
errors, or simply as adverse events. This makes them hard to trace. For
example, a search for 'medical errors' might not turn up this paper from the
Journal of Clinical Nursing because they choose to use the term 'medication
errors'. See:
http://www.blackwell-synergy.com/links/doi/10.1046/j.1365-2702.1999.00284.x
To put the whole issue into perspective you might like to check this
PowerPoint presentation prepared by Richard Smith, Editor of the British
Medical Journal (BMJ). Slide 40 asks:
How dangerous is health care?
Less than one death per 100 000 encounters
a.. Nuclear power
b.. European railroads
c.. Scheduled airlines
One death in less than 100 000 but more than 1000 encounters
a.. Driving
b.. Chemical manufacturing
More than one death per 1000 encounters
a.. Bungee jumping
b.. Mountain climbing
c.. Health care
You will also find that Slides 35 to 39 also report directly on this topic.
Cheers,
Pat Naughtin
PO Box 305 Belmont 3216
Geelong, Australia
61 3 5241 2008
Pat Naughtin is manager of http://www.metricationmatters.com an internet
website that focuses on the many issues, methods and processes that
individuals, groups, companies, and nations use when upgrading to the metric
system. Contact Pat Naughtin at [EMAIL PROTECTED]
