"It should be no surprise that preventable adverse events that harm patients are frighteningly common in this highly technical, rapidly changing, and poorly integrated industry," he wrote. "The picture is further complicated by a lack of transparency and limited accountability for errors that harm patients."
And many of these deadly errors may not even be considered errors by the people who make them.
James draws these conclusions based on studies that used IHI's Global Trigger Tool to flag suspicious findings in medical records, "such as medication stop orders or abnormal laboratory results, which point to an adverse event that may have harmed a patient."
He also extrapolated data from two Office of Inspector General reports and a North Carolina study that quantified these events for limited periods of time or small numbers of hospitals.
James cites the particularly disturbing survey findings of Eric Campbell, Director of Research at the Mongan Institute for Health Policy at the Harvard/Massachusetts General Hospital, published in the Annals of Internal Medicine a few years ago.
Campbell found that physicians said they "often refuse to report a serious adverse event to anyone authority." Cardiologists in particular, who as a group exhibit "the highest nonreporting group of the specialties studied," said they had "recently refused to report at least one serious medical error, of which they had first-hand knowledge."
Obviously, James says, this is "clear evidence of such unreported medical errors [that] often did not find their way into the medical records" of harmed patients.
To me, this is macabre.
2. A Cascade of Errors
It's not only deaths due to medical errors that are regrettable. Patients who survive adverse events can be harmed in ways that will haunt them for the rest of their lives.