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Findings Highlight Limitations of Identifying Errors, Direct Link With Patient Outcomes
July 24, 2001 — Nearly one-fourth of hospital patient deaths analyzed by trained physician reviewers were rated at least possibly preventable, if medical care had been optimal. But the probability that medical error actually caused the death was often considered to be low, and many of the patients who died had little likelihood of survival even with optimal care, according to an article in the July 25 issue of The Journal of the American Medical Association.
Rodney A. Hayward, M.D., and Timothy P. Hofer, M.D., M.S., of the Veterans Affairs Ann Arbor Healthcare System and the University of Michigan Schools of Medicine and Public Health in Ann Arbor, examined the reliability of reviewer ratings of medical error and the implications of a death described as "preventable by better care" in terms of the probability of immediate and short-term survival, if care had been optimal. Fourteen board-certified, trained internists conducted 383 reviews of 111 hospital deaths at seven VA medical centers from 1995 to 1996.
According to background information cited in the article, a recent Institute of Medicine report quoted rates estimating that medical errors account for between 44,000 and 98,000 deaths per year in U.S. hospitals. These widely quoted statistics have helped create important initiatives directed at patient safety throughout the United States. However, some have questioned the validity of these estimates.
These statistics are generally based on peer review, using structured implicit review instruments. Physicians are trained to review hospital medical records using standard review forms and give their opinion on whether adverse events have occurred and the quality of hospital care and its impact on patient outcomes.
For their study, the authors over-sampled for patients with characteristics previously found to be associated with high rates of preventable deaths. Patients considered terminally ill who received comfort care only at admission were excluded. Physician reviewers used a previously tested structured implicit review instrument. Reviewers used a 5-point scale to estimate whether deaths could have been prevented by optimal care. The probability that patients would have lived to discharge or for three months or more, if care had been optimal, was rated from zero to 100 percent.
"However, after considering three-month prognosis and adjusting for the variability ... of reviewers' ratings, clinicians estimated that only 0.5 percent of patients who died would have lived three months or more in good cognitive health if care had been optimal, representing roughly one patient per 10,000 admissions to the study hospitals," the authors report.
"Three caveats were identified that have implications for preventable deaths: (1) the probability that the error actually caused the death was often considered to be low; (2) reviewer assessment of errors had poor reliability ...; and (3) the underlying short-term prognosis of the person who died was often judged to be very limited," they write.
The authors believe their data place the estimates of preventable deaths in context, pointing out the limitations of this means of identifying medical errors and assessing their potential implications for patient outcomes.
"Medical errors are undoubtedly common and contribute to many adverse outcomes," the authors write. "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 by 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," the authors conclude.