A new study by two physicians working for the Veterans Administration suggests that previous studies of mortality due to medical error have greatly overestimated the number of medical error-related deaths. According to researchers Rodney A. Hayward, MD and Timothy P. Hofer, MD, MS, previous studies have not addressed the likelihood of mortality in the absence of error. That is, would patients who died because of a medical error have died even if there had been no error.
In their conclusion, Hayward and Hofer say, “Medical errors are undoubtedly common and contribute to many adverse outcomes. However, if our results can be generalized to other hospitals, the statistics on deaths due to medical errors do not accurately reflect the view of most physician chart reviewers. Our results suggest that these statistics are probably unreliable and have substantially different implications than has been implied in the media and others. Most importantly, this study demonstrates the limitations of this means of identifying errors and highlights that caution is warranted when establishing causal relationships between errors and patient outcomes.”
Hayward and Hofer caution that their results are based on a study of 383 reviews of 111 hospital deaths that occurred at seven different VA medical centers, and that the special circumstance of VA medical centers (caring for older, sicker patients) may not necessarily be representative of hospitals in general.
CME providers will want to see the complete study to determine implications for their own needs assessment regarding courses intended to prevent medical error. In particular, the finding that it is very difficult to find patterns of care that result in truly preventable deaths may be of interest.
See the full report at the Journal of the American Medical Association website
