John James

John T. James PhD, a patient safety advocate in our Safe Patient Project network, has published a new study in the Journal of Patient Safety that estimates the number of patient deaths associated with hospital care is more than 400,000 a year. James’ estimate revises an outdated Institute of Medicine 1999 estimate of 98,000 patient deaths a year from medical errors. His numbers should awaken the public to this leading cause of death in America. In this special guest blog post, John tells us what motivated him to come up with this new medical harm estimate. 

I published my estimate of harm to patients in hospitals as a result of medical errors (preventable adverse events) for 3 reasons. First, I knew the often-quoted estimate of up to 98,000 deaths/year from the IOM was outdated and only the tip of the iceberg. Replacement of that estimate was long overdue. Second, studies published in 2010 and 2011 using primarily the Global Trigger Tool to find more potential medical errors was first applied to relatively large populations of hospitalized Americans. Third, despite the IOM estimate and others, the public remains unaware of the risk to their life from medical errors; I hoped that a contemporary estimate would awaken the public.

The Global Trigger tool has some important limitations, but based on its ability to identify potential adverse events in medical records, one could glean an estimate of 210,000 deaths per year from preventable adverse events, including hospital acquired infections and medication errors. What the tool misses are the following: most errors of omission, errors obscured or missing from medical records, diagnostic errors, errors of context, and most errors of communication. Studies and estimates published in the past few years give us a handle on how frequent these “missed” errors might be. These studies show that medical records are often incomplete and omit evidence of serious medical errors that could be identified by patients who were harmed (verified later by medical investigators). Several studies have shown that medication errors directly observed by a skilled observer are not evident in medical records. One survey of physicians showed that they sometimes refuse to disclose serious medical errors of which they have first-hand knowledge.

My personal experience was also a factor here. Medical errors in the care of members of my family were common and typically obscured in medical records. Private conversations I had with highly-placed physicians suggested that medical errors were far more common than the public recognized or the provider community acknowledged. My readings of medical literature continued to turn up studies showing vast underuse, overuse, and misuse of medical care.

I “adjusted” the core estimate of 210,000 errors to 440,000 based on the many types of errors missed by the Global Trigger Tool and not evident in medical records. I tried not to exaggerate my final estimate by choosing correction factors that were below those suggested by published studies. For example, Weismann’s study published in 2008 showed that serious medical errors were underrepresented in medical records by a factor of 3. I did not use nearly that large of a factor to adjust the “core” estimate.

The reality is that medical care in hospitals is extremely complex and often peppered with errors, and transparency into the occurrence of such medical errors is kept minimal by hospital culture and human nature. It is time that a clueless public wake up to the widespread harm of medical errors and force changes in the system that can give reasonable assurance of safe care. But, as I was warned once by an IOM official, changing the system is not going to be easy because too much money is being made by keeping things the way things are.

Post by John T. James, PhD. Learn more about John’s work to expose the truth about medical harm at Patient Safety America.