40 percent of malpractice claims are for diagnostic errors

By Terry A. Rondberg, DC

Journal of the AMA - logoA commentary published in the July 28 issue of the Journal of the American Medical Association (JAMA) revealed that diagnostic errors are the single largest contributor to medical malpractice claims, accounting for about about 40% of all claims and costing approximately $300,000 per claim.

The authors — Mark Graber, MD, of Stony Brook University Medical Center; and Hardeep Singh, MD, MPH, of Baylor College of Medicine — pointed their fingers at everything BUT the practitioners themselves.

“The great majority of diagnostic errors have root causes that derive from the properties of the healthcare setting, organization and practice,” Dr. Graber said. “By working together, cognitive scientists, informaticians, clinicians, and human factors engineers have a unique opportunity to decrease the likelihood of diagnostic error to the extent that the five principles we outline in JAMA can be incorporated into every new medical home.”

The authors discussed a new model of primary care, called the patient-centered medical home, developed and endorsed by the American Academy of Family Physicians, the American Academy of Pediatrics, American College of Physicians, and the American Osteopathic Association.

The model facilitates partnerships between individual patients, their personal physician, and, when appropriate, the patient’s family. Care is assisted by physician “extenders,” nurse empowerment, information technology, and other means to assure that patients get care when and where they need and want it in a culturally and linguistically appropriate manner.

The medical home model places emphasis on team-based care, and primary care teams could include not only physicians but also nurses, allied health professionals and personnel, the authors explained.

In this model, the medical doctor would be the gatekeeper and decide what role the “allied” health professions would have. “The physician could take a leadership role, while the entire group collectively takes care of the patient,” explained Dr. Singh.

It’s always heartening to see the medical profession recognize and admit the problems inherent in the current disease-oriented system, such as misdiagnoses, prescription errors, unnecessary surgeries, etc.

Still, I’ll continue to work toward the time when we supplant the old paradigm of labeling and treating conditions and symptoms with the new holistic view of the human body as a complex system of energy patterns that responds to non-invasive care such as chiropractic and other “energy medicine” approaches. And I especially look forward to the time when we don’t label all wellness and healing modalities as “medicine!”

New Study: Millions of Elderly Given Wrong Drugs

In some traditional cultures, the elderly are revered. In others, they’re taken out to the woods and left to die. Generally, in America, they’re over medicated, often with harmful or useless drugs.

Elderly given wrong drugs - by Terry A. Rondberg, DCA recent study of the records of 470,000 patients over 65 who were admitted to an emergency department (ED) between 2000 and 2006 revealed that nearly 17% were given what the medical industry refers to as “potentially inappropriate medications (PIMs)” — in other words, the wrong drug.

“Approximately 19.5 million patients … of eligible ED visits were associated with one or more PIMs,” researchers concluded in their report, published in the March 2010 issue of Academic Emergency Medicine journal (2010; 17:231).

“There are certain medications that probably are not good to give to older adults because the potential benefits are outweighed by potential problems,” admitted lead author, William J. Meurer, MD.

The two worst offenders, which accounted for nearly 40% of the errors, were the drugs promethazine and ketorolac. Promethazine is a powerful and potentially risky sedative which can cause everything from confusion in older patients to, in rare cases, seizures. Ketorolac is a non-steroidal anti-inflammatory drug (NSAID) used as an analgesic, fever reducer, and anti-inflammatory.

This isn’t the first time such results have been shown. In July 1994, the Journal of the American Medical Association reported on a study that revealed close to 25% of all elderly patients received wrong drugs.

Among their findings:

** 1.8 million older people had prescriptions for dipyridamole, a blood thinner that, the researchers say, is useless for all except people with artificial heart valves.

** More than 1.3 million older Americans were given prescriptions for propoxyphene, an addictive narcotic that is no better than aspirin in relieving pain.

** More than 1.2 million were prescribed diazepam or chlordiazepoxide, long-acting sedatives and sleeping pills that can make patients groggy, dizzy, and prone to falls.

“Standard published sources support the view that the 20 drugs in our primary analysis should virtually never be prescribed for the elderly,” researchers stated at the time.

One doctor, Jerry H. Gurwitz, MD, of Brigham and Women’s Hospital in Boston, was quoted in The New York Times as saying he hoped the study would serve as “a wake-up call” to America’s doctors. “I hope that the medical community will take it as seriously as the general public, I think, will,” he said, adding that the study might have actually understated the problem since it did not factor in drug interactions or the long-term effect of drugs like sleeping pills.

If we aren’t going to revere our elderly, it might be kinder to leave them in the woods!

Medication Errors Continue to Plague Hospitals

Tragic news yesterday as a 23-month-old girl died following an overdose of a blood thinner (Heparin) at Nebraska Medical Center. The story says “hospital officials are investigating,” but we already know what they will discover. This tragedy was preventable.

Medication errors concern
Percentage of ANA nurses who "worry" about medication errors (2007 survey).

Just ask actor Dennis Quaid. It was announced today that he is starring in a new documentary to help raise awareness about medical errors — three years after his newborn twins were given a drug overdose (also happened to be Heparin) at an L.A. hospital — which almost killed them.

Following is an article I wrote a few years back on medication errors. It’s a sad commentary on our healthcare system that these errors are still so commonplace. Prescription errors are so prevalent in hospitals and long-term care facilities that it has been estimated an average of one mistake per patient per day is made. Of course, most of these errors are not so serious as to lead to serious injury or death, but just ask yourself: are non-lethal errors any more acceptable?

-Dr. Terry Rondberg

Hospital admission = medication errors

By Terry A Rondberg, DC

According to an article appearing in the Archives of Internal Medicine, hospital admissions commonly produce medication errors, some with the potential to be harmful. Background information pointed out that although the admission process routinely includes a medication use history, errors in the history may mean a failure to detect drug-related problems, or lead to interrupted or inappropriate drug therapy during a patient’s stay.

While previous studies had suggested these errors are a potentially serious safety issue, the current study was designed to identify unintended discrepancies between physicians’ admission medication orders and a comprehensive medication use history, and the potential clinical significance of the discrepancy.

Patricia L. Cornish, BScPhm, of the University of Toronto, and colleagues screened medical charts from three months of admissions to the general internal medical clinics at an affiliated hospital. One hundred and fifty-one patients were included in the study who reported use of at least four medications and were either able to communicate or had a caregiver who could communicate for them.

A pharmacist or trained pharmacy or medical student visited patients after allowing 48 hours for clarification of admission medication orders and corrections of problems in the normal course of care. The team member conducted a thorough history of the patient’s regular medication use, relying on a patient or caregiver interview, an inspection of prescription vials, and follow up with a community pharmacy.

Discrepancies between physicians’ admission medication orders and the follow-up history were divided into four types of discrepancies: a drug omission, incorrect dose, incorrect frequency of dose, and an incorrect drug.

These were then further judged to fall into one of three classes of potential severity: Class one – unlikely to cause patient discomfort or clinical deterioration; class two – having the potential to cause moderate discomfort or clinical deterioration; and class three – with the potential to cause severe discomfort or clinical deterioration.

53.6% of patients had at least one unintended discrepancy.

“We identified 140 unintended discrepancies among these 81 patients,” wrote the authors. “The most common error (46.4%) was omission of a regularly used medication. Most (61.4%) of the discrepancies were judged to have no potential to cause serious harm. However, 38.6% of the discrepancies had the potential to cause moderate to severe discomfort or clinical deterioration.”

The authors concluded: “The data presented herein suggest that the processes for recording medication histories on admission to the hospital are inadequate, potentially dangerous, and in need of improvement. To improve patient care and minimize the potential costs of preventable adverse drug events, the health care system should explore ways to improve the accuracy of the hospital admission medication history.”

SOURCE: Patricia L. Cornish; Sandra R. Knowles; Romina Marchesano; Vincent Tam; Steven Shadowitz; David N. Juurlink; Edward E. Etchells: “Unintended Medication Discrepancies at the Time of Hospital Admission,” Archives of Internal Medicine, 165:424-429.