The trouble with the world
is that the stupid are cocksure
and the intelligent are full of doubt.
— Bertrand Russell
Makary and Daniel noted that a “medical error” may or may not cause harm to the patient and defined an error as:
- An unintended act (either of commission or omission);
- An act that does not achieve its intended outcome;
- The failure of a planned action to be completed (an error of execution);
- The use of a wrong plan to achieve an aim (an error of planning); or
- Deviation from the process of care.
Cognitive-proximity biases; the Kübler-Ross sequence of denial and anger; the psychological need to assign blame; the risks associated with procedural management of cancer or cardiovascular disease in an unstable, aging population; and retrospective cause-and-effect attributions are all driving factors in random catastrophic lethal events being attributed inappropriately to healthcare provider-caused errors.
Preventable systematic lethal or egregious human errors do occur, but overall they are relatively small in number compared with random, unpreventable events. Oversight efforts to prevent these errors (eg, electronic health records) can have the opposite unintended consequence of increased random events, because quality provider-patient clinical ‘face time’ is reduced.
Other clinicians from the “error happens” camp believe that systems, not humans, are largely to blame for errors. A registered nurse explained. “System errors, not people intent on making mistakes, are the main culprit. Tort reform is much needed because many family members who feel the pain of loss are eager to punish someone for a loved one’s death.”
Errors are not the fault of physicians but of systems. Human disease and top causes of death have changed from acute infections to chronic problems, but the mindset that drugs and interventions that worked so well in the past are also the solution in today’s world is wrong. It is a sign that medicine needs to change with the times. We should be putting more emphasis on preventive medicine, holistic approaches, and physiological nutrition, because the drugs and interventions are doing nothing to stop the top killers.
There may no doubt that many deaths are due to clinician, nursing, and pharmacy error. Yet nowhere is it accounted for that the population as a whole is horribly sick from their own devices
Death certificates depend on International Classification of Diseases (ICD) codes for cause of death, so causes such as human and system errors are not recorded on them.
People tend to hold overly favorable views of their abilities in many social and intellectual domains. The authors suggest that this overestimation occurs, in part, because people who are unskilled in these domains suffer a dual burden: Not only do these people reach erroneous conclusions and make unfortunate choices, but their incompetence robs them of the metacognitive ability to realize it. Across 4 studies, the authors found that participants scoring in the bottom quartile on tests of humor, grammar, and logic grossly overestimated their test performance and ability. Although their test scores put them in the 12th percentile, they estimated themselves to be in the 62nd. Several analyses linked this miscalibration to deficits in metacognitive skill, or the capacity to distinguish accuracy from error. Paradoxically, improving the skills of the participants, and thus increasing their metacognitive competence, helped them recognize the limitations of their abilities.
Has it ever seemed to you that less competent people rate their competence higher than it actually is, while more competent people humbly rate theirs lower?
It’s not just your imagination. This is a genuine cognitive bias called the Dunning-Kruger Effect.
The Dunning-Kruger experiments behind the research focused on cognitive tasks (logic, grammar, and evaluating humor), but similar disparities exist in other areas. In self-assessment of IQ, below-average people overestimated their score and those above average underestimated.
Studies of healthy and unhealthy behaviors are handicapped when they rely on self-reporting because test subjects tend to improve their evaluation. In self-evaluations of driving ability, job performance, and even immunity to bias, we tend to polish our image.
This is called the Lake Wobegone Effect, named after the town where “all the children are above average.”
Notice that there are two different categories of error:
(1) the error where there is a preferred answer and most people are biased toward giving that answer (“How much snack food do you eat?” or “How popular would you say you are?” or “How good a driver are you?”), and
(2) the error where bias changes depending on actual competence, with the less and more competent groups rating themselves too high and too low, respectively.
Let’s look at the second category, where the two extremes make opposite errors. The Dunning-Kruger research hypothesizes that the competent overestimate others’ skill levels. But the error is more complicated for the incompetent—they overestimate their own skill level and they lack the metacognition to realize their error. In other words, they were too incompetent to recognize their own incompetence. Improving their metacognitive skills drove down their self-assessment scores as they became better evaluators of their own limitations.
According to the CDC, in 2013, 611,105 people died of heart disease, 584,881 died of cancer, and 149,205 died of chronic respiratory disease—the top three causes of death in the U.S. The newly calculated figure for medical errors puts this cause of death behind cancer but ahead of respiratory disease. Analyzing medical death rate data over an eight-year period, Johns Hopkins patient safety experts have calculated that more than 250,000 deaths per year are due to medical error in the U.S. Their figure, published May 3 in The BMJ, surpasses the U.S. Centers for Disease Control and Prevention’s third leading cause of death—respiratory disease, which kills close to 150,000 people per year. Most errors represent systemic problems, including poorly coordinated care, fragmented insurance networks, the absence or underuse of safety nets, and other protocols, in addition to unwarranted variation in physician practice patterns that lack accountability.
The authors also suggest that hospitals carry out a rapid and efficient independent investigation into deaths to determine whether error played a role. A root cause analysis approach would help while offering the protection of anonymity. It’s public pressure that brings about change. Hospitals have no incentive to publicize errors; neither do doctors or any other provider. However, such a major step as adding error information to death certificates is unlikely if not accompanied by tort reform. Medical Error Is Third Leading Cause of Death in US
Medical error in the US Excerpt See article below:
Analyzing medical death rate data over an eight-year period, Johns Hopkins patient safety experts have calculated that more than 250,000 deaths per year are due to medical error in the U.S. Their figure, published May 3 in The BMJ, surpasses the U.S. Centers for Disease Control and Prevention’s third leading cause of death—respiratory disease, which kills close to 150,000 people per year.
The Johns Hopkins team says the CDC’s way of collecting national health statistics fails to classify medical errors separately on the death certificate. The researchers are advocating for updated criteria for classifying deaths on death certificates.
“Incidence rates for deaths directly attributable to medical care gone awry haven’t been recognized in any standardized method for collecting national statistics,” says Martin Makary, professor of surgery at the Johns Hopkins University School of Medicine and an authority on health reform. “The medical coding system was designed to maximize billing for physician services, not to collect national health statistics, as it is currently being used.”
In 1949, Makary says, the U.S. adopted an international form that used International Classification of Diseases billing codes to tally causes of death.
“At that time, it was under-recognized that diagnostic errors, medical mistakes, and the absence of safety nets could result in someone’s death,” says Makary, “and because of that, medical errors were unintentionally excluded from national health statistics.”
In their study, the researchers examined four separate studies that analyzed medical death rate data from 2000 to 2008. Then, using hospital admission rates from 2013, they extrapolated that based on a total of 35,416,020 hospitalizations, 251,454 deaths stemmed from a medical error, which the researchers say now translates to 9.5 percent of all deaths each year in the U.S.
According to the CDC, in 2013, 611,105 people died of heart disease, 584,881 died of cancer, and 149,205 died of chronic respiratory disease—the top three causes of death in the U.S. The newly calculated figure for medical errors puts this cause of death behind cancer but ahead of respiratory disease.
“Top-ranked causes of death as reported by the CDC inform our country’s research funding and public health priorities,” Makary says. “Right now, cancer and heart disease get a ton of attention, but since medical errors don’t appear on the list, the problem doesn’t get the funding and attention it deserves.”
The researchers caution that most medical errors aren’t due to inherently bad doctors, and that reporting these errors shouldn’t be addressed by punishment or legal action. Rather, they say, most errors represent systemic problems, including poorly coordinated care, fragmented insurance networks, the absence or underuse of safety nets, and other protocols, in addition to unwarranted variation in physician practice patterns that lack accountability.
“Unwarranted variation is endemic in health care,” Makary says. “Developing consensus protocols that streamline the delivery of medicine and reduce variability can improve quality and lower costs in health care. More research on preventing medical errors from occurring is needed to address the problem.”