Thankfully I haven't had many reasons to enter a U.S. hospital, but the few interactions I had were extremely worrisome.
For example, when my grandmother fell ill, my family spent a lot of time visiting her. My mother, in particular, spent many days and nights there, and her biggest complaint was the complete lack of communication between shifts.
Every few hours, someone new would come into the room, read my grandmother's charts, wake my grandmother up, and ultimately misinterpret several important details. Thankfully my mother was often there to correct them and fill them in on what previous nurses/doctors had already done, but the net result was that my grandmother barely got any rest (being constantly woken for no apparent reason) and, had my mother not been there, a nurse or doctor could easily have made a critical mistake when continuing her treatment.
Another example, still the same grandmother. Even though her original condition improved (after having been rushed to a different hospital), she ended up going home with an entirely new infection which resulted in several more weeks of sickness and eventual recovery. The infection (C. Diff) is one of the leading Hospital-acquired infections and is in many cases totally preventable. It's hard to believe how many people die each year due to infections they pick up in hospitals.
We're addressing this problem at Care Thread (http://www.carethread.com), where we integrate patient-centered messaging and EMR data to ensure that everyone stays in the loop.
Existing electronic medical records systems are at their best for long-term documentation, and fall short on keeping care providers abreast of ever-changing plans across shift transitions. Pagers and phones, which doctors and nurses use instead for real-time communication, fare even worse. The information is simply invisible to the next person who takes over.
We've had terrific, sustained adoption where Care Thread's system is deployed, and are working to measure the effect on patient outcomes. Some study results are pending (from Partners / Brigham & Women's Hospital in Boston, where researchers put iPads in the hands of patients and used our mobile messaging system to help keep care providers aligned with each other and with patients).
> her biggest complaint was the complete lack of communication between shifts.
Hmm seems weird and easily addressable to me, I had to spend some time in a hospital in Paris (France) and the staff had a meeting between every shift to discuss how patients were going. To the point that people complained they weren't available at that time... But yeah no experience with US hospitals so YMMV.
Note the paper's definition of medical error:
"Medical error has been defined as an unintended act (either of omission or commission) or one that does not achieve its intended outcome,3 the failure of a planned action to be completed as intended (an error of execution), the use of a wrong plan to achieve an aim (an error of planning),4 or a deviation from the process of care that may or may not cause harm to the patient."
This disclaimer needs to be included in any conversation about this study. In the same week that John Oliver ranted on the dangers of misleading scientific studies[1] we see headlines like "Medical error in hospitals is the third leading cause of death in the U.S." with no mention of the fact that this study qualifies an "error" as anytime a doctor isn't a perfect healing machine.
Is it? Those all seem like pretty reasonable types of error. Ultimately they have to have contributed to the death of a patient to be included. If one of those things contributed to someone's death, I don't think i'd hesitate to call that a 'medical error'.
I struggle to see how there are any deaths inside a hospital that don't fall into this category. E.g. a cancer patient on chemo therapy who doesn't make it would seem to qualify.
Realistically I assume this means that they count whatever they want as medical error, with no good rules.
I don't think your example would qualify unless a real error was made e.g. the chemo killed them so there was a planning error in putting them on chemo. The truth is that many people with cancer will not survive. In those cases, chemo is not about saving their lives, just extending them.
You're saying what it should be but the parent comments are talking about what it actually says. Specifically, "one that does not achieve its intended outcome".
I'm arguing that the "intended outcome" isn't always complete recovery. If a patient with terminal cancer dies, that doesn't necessarily mean that the chemo didn't achieve its intended outcome.
Simply put, the headline of the article kindly submitted here surely exaggerates the actual problem. What's undoubtedly a problem is that we don't yet have good data-gathering about when patients die unavoidably and when they die when they could have been saved by standard-of-care medical treatment.
Maybe because the first paragraph is a non sequitur swipe at the business of alternative medicine and two people in particular. Or maybe because there's apparently an online campaign against the article author.
The first paragraph may not be so random in the blog's context, I expect a blog called Science Based Medicine would spend a lot of time doing battle with alternative medicine adherents, but it detracts from this specific article which does a good job deflating this medical errors headline.
The original study's authors suggest adding a field to death certificates where the hospital personnel would put additional information about the cause of death:
... death certificates could contain an extra field asking whether a preventable complication stemming from the patient’s medical care contributed to the death.
How could they do this and, at the same time, shield themselves from lawsuits which use that "extra field" as evidence against them?
Malpractice limits exist in some jurisdictions in the US. Studies have shown that they do not have meaningful effects on the cost of liability insurance or the practice and cost of healthcare. (Which kind of makes sense: the limits are always adopted to prevent what are seen to be "extreme" awards which are awarded -- from the perspective of proponents of the limits -- by runaway courts/juries, or -- from the perspective of opponents -- for the most egregious incidents of malpractice; these make up a very small share of all awards and have a negligible effect on either a practitioner's or an insurer's exposure. You'd have to limit malpractice awards at a level that would affect common and uncontroversially warranted awards to have a meaningful effect.)
For a system that appears to be having a problem putting in quality controls, limiting liability runs the risk of having those limited payouts turn into a cost of doing business.
OTOH doctors now do serious liability limitation by constantly worrying over their exposed "attack surface" in case something goes wrong. Having your medical staff being forced to be more worried about legal repercussions than well-being of their patients is not exactly healthy for anyone involved.
Compare with aviation industry, where considerable effort was made to treat accidents as systemic problems and a) making sure individuals won't get immediately blamed for stuff that's not really their fault, and b) that everyone can learn as much as possible from every mistake made so that they don't happen again.
Well if you publish these cases online the hospital will lose substantial business. So it's like a canary. At least you are getting information about what's going wrong, and then you can put pressure on the management to fix it via other means like regulation, penalties, or whatever.
That has the unfortunate effect of anchoring the amount so many people who would have sued for a modest amount see the limit and sue for that amount instead.
Hospitals are a mix of stakeholders, all of whom have different agendas. There's something to be said for a blame-free environment where you can actually get honest post-mortem assessments.
So they could have a consequence-free way to accumulate analytics to make healthcare better. If you have no metrics of a problem, you have no idea how big the problem is, right? Or if a problem needs to be solved. Or how.
Disappointing, sad, and scary, but not unexpected. You can’t expect matters of life and death that effect liability, public relations, and profitability to be properly investigated and resolved by the entities directly involved. When an airplane crashes, the airlines, manufacturers, and pilots union don’t get to run the investigation and choose the results. Sure they are involved and try to influence the outcome, but an external agency heads the investigation.
Medicine needs some sort of non-punitive external investigative agency. With the scope so much larger than aviation and death often being a normal outcome, how to structure such an agency would be challenging, but I still think it’s the only way to really address the problem. The same applies for law enforcement and the use of deadly force. While many of the people involved have the best intentions, the pressures of the organization put undue bias on any internal investigation.
It looks like an agency along these lines may have been formed [1], but the ‘At the invitation of healthcare providers’ isn’t good enough. A quick google search found others pushing along these lines [3], and it’s interesting that they are talking about error being the ‘third leading cause of death’ in 2014.
While critics point out that the study may have an overly broad definition of error, it still seems that there is an issue here from anecdotal experience, and that error shouldn’t even be in the top 10.
I wonder how many of those deaths were in public healthcare and in private healthcare?
Speaking as a swede I am fed up with seeing how the government undermines public health care at every turn and promoting privatized health care. Health care workers aren't stupid, they're mass migrating from public to private sector. Leaving the public sector in very bad shape with no backup from the government to keep it running.
If you like me believe that your health should not be measured by your wealth then it's down right disgusting.
I am ROUTINELY prescribed medication that I am not supposed to take.
I have a drug allergy, and one other simple condition that both preclude certain medications being prescribed to me. These conditions do not change over time, and have been in my medical history for 20+ years and yet multiple providers have prescribed medication I can't take to me. I cross check all new prescriptions myself as a matter of course now.
I can't say I'm surprised. I had a surgery once at a supposedly well-respected regional hospital, and they made several careless mistakes with me. Everything turned out fine, but there was considerable opportunity for easily preventable things to have gone wrong if it weren't for dumb luck.
nothing to do with death, but how hospitals don't know what they are doing sometimes.
when I was really young I jammed my finger. went to the hospital to get it checked. they were putting a wrist splint on me. I asked how that helped my finger. he quickly took it off.
The book "Black Box Thinking" by Matthew Syed has good insight on this issue, especially the differences between how the airline and medical industries handle errors.
In many arguments about socializing medical care, the "fact" that the US has "the best medical care in the world" is cited as a reason to keep the status quo. instead it appears we are paying through the nose for a system that doesn't manage quality very well at all.
Check out the CONCORD study, which compared cancer survival rates across 18 countries.
The US had the highest overall survival rate (73.8%). Countries with government-run medical care, like UK and Denmark, had the lowest: 51-52.8%.
The difference is especially dramatic for prostate cancer, where the US has a 92% survival rate, Australia and Canada were at 77-85% [1], and Denmark was at 38%.
It's certainly debatable which countries get the best medical care for the dollar, or which countries distribute it to people in the most fair way, or make it most accessible to the poor. But I don't really think there's debate that the US gives the best medical care if money is no object. My understanding is that, with very few exceptions, the wealthy all over the world come to the US if they have a serious medical condition.
> It's certainly debatable which countries get the best medical care for the dollar, or which countries distribute it to people in the most fair way, or make it most accessible to the poor.
It's not debatable that the U.S. performs relatively poorly by those measures.
> I don't really think there's debate that the US gives the best medical care if money is no object
I've heard people repeat that a lot, but I've never seen evidence of it one way or the other.
> In the absence of me showing you the evidence, what is your honest estimate of the probability that it's true?
I have no reason to think that U.S. healthcare, at the high end, is generally superior to that of other rich countries. My guess is that it depends on the field (some do better in, e.g., oncology and others do better in, e.g., brain surgery); that it might vary by hospital or by doctor more than it varies by country; and that results could depend more on operational issues, such as quality control, than on technology or doctor training.
I'd claim (and bet, if we could settle) that a wealthy informed person would rather by randomly dropped into the top X% of hospitals in the US than the top X% of hospitals of any other country, for X < 10. Furthermore, that the top location in the world for 90% of specialities is located in the US.
Do you disagree, and if so what would your country/numbers be?
> I'd claim (and bet, if we could settle) that a wealthy informed person would rather by randomly dropped into the top X% of hospitals in the US than the top X% of hospitals of any other country, for X < 10.
This isn't an argument that has to take place in the hypothetical. When King Abdullah (Saudi Arabia) had to get open heart surgery, he booked it in the US[0]. This is not an isolated case, just the most famous one. I have a lot of personal stories about this, but I'll just leave it at this.
Medical tourism actually runs in both directions. In the US, people often go to other countries for cheap, routine surgeries. Many Middle Eastern countries, on the other hand, are forming partnerships with US hospitals to bring their (American) doctors to the Middle East for effective 'tours of duty', as their solution to equalizing access to health care. (The very wealthy people living in the Gulf already come to the US for their planned treatments, but the middle class[1] can't quite afford it).
If you talk to the most prestigious physicians and surgeons[2] at the top hospitals in the US (like the very, very top physicians at Mass General or NewYork-Presbyterian), you'll find that a sizeable number of their patients are foreigners - often living in the Middle East.
There is some medical tourism from the Gulf to Europe, but it's nowhere near as widespread, and the general impression in the Gulf is that the US is the pinnacle of care quality, which is why they're chasing US practitioners and practice groups so aggressively.
The fact that some people go to the U.S. for medical care does't mean others don't go to other countries for it. A few anecdotal examples don't tell us anything about a population.
> A few anecdotal examples don't tell us anything about a population.
Aramco - the world's most valuable company - is leaning on Johns Hopkins to staff and run its entire healthcare system. They're not even the only one forming these partnerships with US hospitals and research university - just the most recognizable mame. That's more than just 'ancedotal'.
OP's question was 'which hospital would a wealthy informed person choose'? I'm pointing out that we don't need to speculate, because we already know which one was chosen by the wealthiest company in the world, (owned wholly by the fourth wealthiest country in the world[0]).
[0] The country with the second-largest sovereign wealth fund, by the way, is the UAE, which is also forming the same partnerships (Cleveland Clinic).
It is highly dubious that this is some feature of the expense of medical care in the US. For example, it's generally recommended that for surgery, you actually want to see a doctor who works in the public system (in Australia, my country) because for routine procedures the guy who does them everyday, all the time, is probably a lot better at it then the guy who can choose his cases.
The US has a giant population with first-world levels of funding from the government - it's fairly likely that care quality is simply the intersection of population and experience. But you pay more from the government per person, and get less. Your system and outcomes should be so much better and you all should be angry about that. It's just at some level of size and overall budget, you get a lot despite being inefficient.
> . For example, it's generally recommended that for surgery, you actually want to see a doctor who works in the public system (in Australia, my country) because for routine procedures the guy who does them everyday, all the time, is probably a lot better at it then the guy who can choose his cases.
While I agree that this is the case, the people who are willing to travel for medical care are likely not traveling for routine cases; they are going to see specialists for complex cases. The quality of care varies substantially across the US, and I do think the top tier facilities in the US are some of the best (if not the best) in the world. That says nothing about the average level of care across the country however, and it is typically difficult to get access to these premiere hospitals unless you know someone with connections in medicine or have money.
Be careful even in non-routine cases. The specialist in question may select his patients based on qualifiers that are in his interest. One of them is the likelihood of recovery - high likelihood improves their track record and thus their standing as a specialist.
This is fair point, but at a hospital-level in the US you do tend to see higher mortality levels at prestigious hospitals due to the increase in average case complexity. People are willing to take on the tougher cases.
> I don't really think there's debate that the US gives the best medical care if money is no object. My understanding is that, with very few exceptions, the wealthy all over the world come to the US if they have a serious medical condition.
There's a number of individual places in the US and Europe (and possibly some elsewhere) that attract the rich from all over the world, based on reputation as providing the best care for particular conditions. But the US as a whole does not provide the best overall quality of healthcare (outcomes are about average for the developed world) even before considering overall cost, and has overall cost (whether looked at per GDP or per capita) much higher than the rest of the developed world (per GDP, government spending on healthcare in the US is at a fairly typical level for a developed world country where the vast majority of all health spending is by the government, and private spending on healthcare in the US exceeds government spending.)
The inefficiency and wastefulness of US healthcare compared to the rest of the developed world -- most of which have considerably more government involvement in and control of healthcare -- is quite notable.
I don't think the fact that wealthy people from all over the world come to the US is an important factor in evaluating the overall health system. The deciding factor should be what the average citizen gets out of it.
Otherwise Italy could claim they are building the best cars in the world by having Ferrari and Lamborghini.
Based on data, or based on image and marketing? [EDIT:] Interesting pair of replies: US medicine is envied by those "trapped" in socialized systems that won't give them a private room. AND over-regulation is the cause of quality problems. Now there's a 360 degree defense of market-based medicine!
It's already been pointed out that Lamborghinis don't make Italy the world's best car-making country. And Lamborghinis are not even the world's best cars. The rich are particularly susceptible to irrational decisions about purchases.
The medical industry is already the most highly regulated sector of the American economy, it is not an example of a failure of laissez-faire captilism.
As medicine advances and hospital care improves, wouldn't you ultimately arrive at a happy end where mistakes are, in fact, a leading cause of death?
In the aggregate and over time, "mistake" is definitely a more desirable cause of death than "we did not know how to fix him," or "we could not afford the machine," or "we did not have enough of the right pills."
Depends on the rate of course. If mistakes killed most of the inmates then no, not happy. And mistakes are often avoidable at little cost, so especially tragic.
Yes, absolutely. I do think my point holds, though–it is not axiomatic that it is indicative of bad care that medical mistakes are rising as a proportional cause of mortality.
To me quality in medicine can be split into (1) what ailments are treated, (2) success rate, (3) accident rate and (4) how large the percentage of those eligible for treatment is.
For example, when my grandmother fell ill, my family spent a lot of time visiting her. My mother, in particular, spent many days and nights there, and her biggest complaint was the complete lack of communication between shifts.
Every few hours, someone new would come into the room, read my grandmother's charts, wake my grandmother up, and ultimately misinterpret several important details. Thankfully my mother was often there to correct them and fill them in on what previous nurses/doctors had already done, but the net result was that my grandmother barely got any rest (being constantly woken for no apparent reason) and, had my mother not been there, a nurse or doctor could easily have made a critical mistake when continuing her treatment.
Another example, still the same grandmother. Even though her original condition improved (after having been rushed to a different hospital), she ended up going home with an entirely new infection which resulted in several more weeks of sickness and eventual recovery. The infection (C. Diff) is one of the leading Hospital-acquired infections and is in many cases totally preventable. It's hard to believe how many people die each year due to infections they pick up in hospitals.