| | Magnitude
of the Problem
The "Human Factors
MD Index"
The past decade has seen the
problem of medical error come to light. Here is our version of the Harper's
Magazine Index applied to the problem of medical error:
| | Estimated
number of deaths per year in the US hospital system attributable to medical error:
| 98,000 |
| | Number
of jumbo jet crashes required per day for equivalent death rate: |
1.5 | | | Rank
of medical errors among leading causes of death in the US: |
5th | | | Rank
of medical errors among causes of death relative to motor vehicle accidents, diabetes,
kidney disease, breast cancer, and influenza: |
1st | | | Percentage
of anesthesiologists who, when surveyed anonymously, admitted to committing an
error with fatal results: |
24 | | | Percentage
of Americans who estimate that medical error causes fewer than 5,000 deaths annually: |
60 | | | Percentage
of Americans who are "very concerned" that an error or mistake will
lead to serious injury or harm when flying in a commercial aircraft: |
32 | | | Percentage
of Americans who are "very concerned" that an error or mistake will
lead to serious injury or harm when going to a hospital for care: |
47 | | | Percentage
of Americans who believe they have personally experienced a medical error: |
42 | | | Estimated
annual cost of medical error to US healthcare system: |
$24 billion | (Sources:
1, 10 IOM To Err is Human,
3, 4 WrongDiagnosis.com,
6, 7, 8, 9Kaiser
Health Poll Report 2003, 5 Anesthesiology, 63:A497, 1985) Errors
Attributable to Poor Device Design Of course, not all errors
involve medical devices or stem from poor device design. Errors take several forms,
including: Diagnostic Errors,
such as misdiagnosis leading to an incorrect choice of therapy, failure to use
an indicated diagnostic test, misinterpretation of test results, failure to act
on abnormal results;
Treatment Errors, such
as errors in the use of a drug, administering the wrong drug, adverse drug reactions,
errors in administering to a patient, delay in treatment;
Preventative
Errors, such as failures to provide an indicated prophylactic treatment,
inadequate monitoring or follow-up of treatment;
Device
Use-Errors, incorrect programming of a dosage, failure to respond to an
alarm, misreading displayed information, data entry errors, inadvertent switch
activation. And while we at Human Factors MD are unaware
of statistics on the frequency of device use-errors, it is clear that errors caused
by poorly designed devices are part of the medical error problem. Here are some
disturbing examples: Free Flow: The Silent Killer From
1995 through 2000, registered nurses fatally overdosed 39 patients and injured
373 others while handling infusion pumps capable of delivering rapid, uncontrolled
bursts of medicine through intravenous lines. In each case, a nurse switched off
the pump but failed to manually engage a small roller clamp on the IV line which
stops the "free flow" of medicine. (Source: Chicago Tribune, September
11 2000). Therac 25
1986, Ray Cox, a Texas oil worker, received radiation treatment for a tumor
he had removed from his left shoulder. A typing error, software bug, and uninformative
error message (Malfunction 54) lead the radiation therapy technologists to deliver
three "blasts" of 25000 rads: about 125 times the normal dosage. Ray
Cox's health deteriorated rapidly from radiation burns and other complications
from the treatment overdose. He kept in good humor about his condition, joking
that "Captain Kirk forgot to put his machine on stun". He died four
months later. (Source: Casey, Steven. Set Phasers On Stun, And Other True Tales
of Design, Technology, and Human Error. Aegean Publishing Company, 1998)
Death by Decimals
An
RN programmed an infusion pump to give two initial doses of pain medication. She
thought the concentration mode was set at 1.0 mg, but it had actually been set
at 10.0 mg by the previous user. After the initial setup, the pump does not indicate
the concentration mode. The patient was given two initial doses at ten times the
intended dose. The patient arrested but was revived. (Source: Medical Device Safety
Report, FDA)
The ECRI maintains a listing
of "user-errors" pulled from FDA's Medical Device Safety Reports
(select "User Errors" as the "Cause of Incident"). Top^ | |
