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Medical Errors Kill Thousands, Panel Says

TIMES HEALTH WRITER

“Basic flaws” in the U.S. health care system produce medical errors that lead to as many as 98,000 deaths annually, a federally sponsored panel said Monday, and members called for rigorous changes to safeguard patients.

In a highly critical report, a committee of the Institute of Medicine concluded that health care is a decade or more behind other high-risk fields--such as the airline industry--in its attention to basic safety. The report was described by one committee member as one of the most decisive ever issued by the Institute of Medicine, an arm of the National Academy of Sciences.

“The goal of this report is to break this cycle of inaction,” says the document.

“The status quo cannot be accepted or tolerated any longer. . . . It is simply not acceptable for patients to be harmed by the same health care system that is supposed to offer healing and comfort.”

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Between 44,000 and 98,000 people each year die as a result of medical errors--more than die from motor vehicle accidents, breast cancer or AIDS, according to the report. The annual costs of preventable injuries are estimated at between $17 billion and $29 billion.

“The Institute of Medicine has finally blown the whistle on our inability to cope with this pattern of errors,” said institute committee member Dr. Molly Coye, former health services director in California and now a health care consultant for the Lewin Group. “This is definitely a call to action.”

Though most readily detected in hospitals, errors also occur in day-surgery and outpatient clinics, retail pharmacies, nursing homes and patients’ own homes, panelists said.

Doctors’ notoriously poor handwriting too often leaves pharmacists squinting at paper prescriptions. Did the doctor order 10 milligrams or 10 micrograms? Does the prescription call for the hormone replacement Premarin or the antibiotic Primaxin?

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Many drug names sound alike, causing confusion for doctor, nurse, pharmacist and patient alike. Consider the painkiller Celebrex and the anti-seizure drug Cerebyx, or Narcan, which treats morphine overdoses, and Norcuron, which can paralyze breathing muscles.

Medical knowledge grows so rapidly that it is difficult for health care workers to keep up with the latest treatment or newly discovered danger. Technology poses a hazard when device models change from year to year or model to model, leaving doctors fumbling for the right switch.

And most health professionals do not have their competence regularly retested after they are licensed to practice, the report said.

Yet consumers often believe--sometimes mistakenly--that they are protected, according to the report. They rely on licensure of professionals and accreditation of institutions as though these are a “Good Housekeeping seal of approval.”

In fact, institute panelists said, these regulators give only “limited attention” to the issue of medical errors, and, in the process, often encounter resistance from health care organizations and providers.

The 19-member committee found that the fragmented nature of the nation’s health care delivery system “contributes to unsafe conditions for patients and serves as an impediment to efforts to improve safety.”

Patients often go to multiple providers in a variety of settings, making it difficult to coordinate care and information, the report found.

The problem is allowed to continue in part because group purchasers of insurance have not used their clout to demand improvements in safety or quality, the committee noted.

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The report states that there is no “magic bullet” solution to the problem of medical errors. Rather, a combination of fundamental changes is warranted. The idea, panelists said, is to make medical errors so costly to health care organizations and providers that they are compelled to improve safety.

“Given current knowledge about the magnitude of the problem, the committee believes it would be irresponsible to expect anything less than a 50% reduction in errors over five years.”

The committee laid out a national agenda for reducing errors in health care and improving patient safety. Among its recommendations:

* Create a national center for patient safety to set national goals, track progress and issue an annual report to the president and Congress. In addition, the center could develop and fund research, evaluate methods for identifying and preventing errors, and act as a clearinghouse for information about patient safety.

* Create a nationwide mandatory reporting system for medical errors. (About a third of the states have mandatory reporting requirements.) The requirements would apply to hospitals first, and be extended later to other health care providers.

* Consumer groups, employers, licensing and accrediting agencies and the U.S. Food and Drug Administration should increase their pressure and oversight.

* Health care organizations should design systems to catch and prevent errors, rather than attaching blame to individuals.

The Associated Press contributed to this story.

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