The 'Medmal' Mess
When it comes to reducing medical errors, assessing blame is less effective than identifying patterns and steps to correct problems.
If you tuned into any of the recent malpractice insurance debates-- they were held in at least 34 states and the U.S. Congress this year-- you probably didn't learn anything new. All the caricatures we've come to know so well were invoked: rapacious lawyers and greedy patients duking it out against careless doctors and thoughtless hospitals, not to mention incompetent insurance companies, which were running on empty and raising malpractice insurance rates way beyond affordability or common sense.
The debate, of course, has surfaced many times before--most recently in the early 1990s when, during an economic downturn, insurance companies found themselves down on their investment luck and raised premiums to keep the coffers full enough to pay off claims.
What was new this time was the tiny glimmer of light that was beginning to shine on a loaded and unhappy fact: Whether the doctor, the hospital, the patient or the lawyer is the most aggrieved or egregious player, medical errors happen. What happens to information about these adverse events is likely to be the key to straightening out the "medmal" mess.
The existence of errors was given a statistical profile by the federal Institute of Medicine in its 1999 report, "To Err Is Human: Building a Safer Health System." As many as 98,000 hospital patients die of medical mistakes every year, and those mistakes are, according to IM researchers, systemic. That is, they are errors such as medications not given as prescribed, or incorrect dosages, that happen on a regular basis at even the best medical institutions. A 2003 follow-up report by the U.S. Agency for Healthcare Research & Quality found that preventable post-operative complications lead to 32,000 deaths a year.
A study on the quality of health care by RAND, published in the New England Journal of Medicine this June, found that nearly half of Americans don't get the recommended health care they should when they go to the doctor or hospital. Specifically, the California-based research institute reported that 55 percent of heart attack patients did not receive medications that could reduce their risk of death by more than 20 percent.
Additionally, a survey of patients by Health Affairs, which ran in that publication's May issue, found that almost one-fourth of respondents said they had been victims of a medical mistake. And a December 2002 Kaiser Commission study unearthed an even higher rate: 42 percent.
Modern technology can eliminate some of these errors. Computerized systems for medical records and prescription drugs can cut down on mistakes and misunderstandings--to say nothing of problems caused by a physician's illegible handwriting. The federal government is moving in the direction of a technical fix for some of that: The Food and Drug Administration may require that all medications--vials, packages, tubes and other containers--be labeled with bar codes that would be matched to encoded bracelets worn by hospital patients.
State legislators and health care regulators can do something about the error problem, too. They can enact mandatory requirements for hospitals to report adverse events. At present, 17 states require hospitals to report adverse events and five others have voluntary programs. But how they collect the information and what they do with it is critical. The idea is not so much to point fingers but to look for patterns and take actions to correct the problem.
Unfortunately, many of the states report confusion over what events are reportable. In an effort to help, the National Academy for State Health Policy has established a core set of 27 serious and preventable adverse events that should be reported by all licensed health care facilities.
The non-blame approach appears to be what is happening in my home state of Maryland, where the legislature mandated that the health care commission issue reports on the quality of care at the state's 46 acute-care hospitals. As the first step in carrying out this goal, the commission limited its first report to two diseases--heart failure and pneumonia. The plan was to review thousands of medical records to document the percentage of patients at each hospital whose treatment included the most effective drugs, tests and follow-up instructions. To show hospitals how they should collect data, the commission ran a practice session six months before the official review. In some cases, the hospitals spotted their failings and changed policies to meet the standards.
The purpose of the hospital ratings is not to embarrass the acute- care facilities but to bring them along so every hospital can point to as good results as the best-performing hospitals. And the hospitals seem to be complying in a spirit that suggests they see this as an education tool for themselves.
This is a sensible way to tame the medmal beast: If patients aren't harmed, they have no reason to sue.