Death panel: no way. Deadly medical error: happens every day.


Sarah Palin’s assertion that healthcare reform would bring “death panels” empowered to kill sick people in order to save money is pure fantasy, but the idea resonated with the American public. It speaks to people’s deepest fears, that when they are frail and ill, society will take the opportunity to do them in. The irony is that the fear is entirely misplaced. They don’t need to worry that the healthcare system will kill them deliberately; they should be worried that the healthcare system will kill them accidentally.

It is difficult to deliberately die within the American healthcare system. Far from convening “death panels” to withdraw care, providers and hospitals are ignoring the wishes of those who want to die. Advance directives and healthcare proxies have allowed Americans to forgo care at the end of life, yet the majority of these arrangements are ignored, primarily because of fear of lawsuits, and often in the face of intra-family conflicts.

Unfortunately, it is all too easy to die by accident within the American healthcare system. Although claims that “doctors are a leading cause of death” are vastly exaggerated, the number of healthcare errors is extraordinarily high, and the death toll from those errors is far too large.

Dr. Donald Berwick of the Institute for Healthcare Improvement detailed the experience of his wife Ann, hospitalized for a rare spinal problem:

An attending neurologist said one drug should be started immediately, that “time is of the essence.” That was on a Thursday morning at 10 a.m. The first dose was given 60 hours later, on Saturday night at 10 p.m… One medication was discontinued by a physician’s order on the first day of admission and yet was brought by a nurse every single evening for 14 days straight. “No day passed–not one–without a medication error,” Berwick remembers… “The errors were not rare. They were the norm.”

After he publicized his experiences, Berwick was besieged by other doctors saying, “If you think that’s terrifying, wait until you hear my story.” One distinguished professor of medicine whose wife was hospitalized in a great university hospital was too frightened to leave her bedside. “I felt that if I was not there, something awful would happen to her,” he told Berwick. “I needed to defend her from the care.”

The problem first received widespread attention with the publication of Dr. Lucian Leape’s paper in JAMA in 1994, Error in Medicine:

Autopsy studies have shown high rates (35% to 40%) of missed diagnoses causing death. One study of errors in a medical intensive care unit revealed an average of 1.7 errors per day per patient, of which 29% had the potential for serious or fatal injury. Operational errors (such as failure to treat promptly or to get a follow-up culture) were found in 52% of patients in a study of children with positive urine cultures.

Given the complex nature of medical practice and the multitude of interventions that each patient receives, a high error rate is perhaps not surprising. The patients in the intensive care unit study, for example, were the recipients of an average of 178 “activities” per day. The 1.7 errors per day thus indicate that hospital personnel were functioning at a 99% level of proficiency. However, a 1% failure rate is substantially higher than is tolerated in industry, particularly in hazardous fields such as aviation and nuclear power…

It is hardly surprising that errors have become a prominent feature of a system designed to “process” as many patients as possible, as quickly as possible. Doctors are being compelled to see more patients in less time, despite the fact that many more people are living with complex medical conditions. Nurses are compelled to care for many more patients at one time, despite the fact that their medical needs, particularly the need for sophisticated monitoring technology, have grown dramatically, and the patients themselves are sicker.

Most importantly, in an industry where mistakes are a matter of life and death, the underfunding of medical care means that hospitals do not have the money to acquire technology that can reduce errors.

In an update of his report on medical errors published earlier this year, Dr. Leape explains:

Errors and injuries can, in fact, be prevented by redesigning systems to make it difficult, and sometimes impossible, for caregivers to make mistakes. A classic example is the elimination of accidental (fatal) intravenous injections of concentrated potassium chloride by removing the medication from the nursing units and requiring it to be added to intravenous solutions when they are prepared in the pharmacy.

Another example is computerized physician order entry systems (CPOE), where the physician must enter all orders, including all prescriptions for medications, by computer. This ensures that the order is complete, it is not a medication the patient is allergic to, and that the dose is within usual limits… CPOE can reduce serious medication errors by 60–80%.

The healthcare system as it currently exists unwittingly conspires to increase errors. When it comes to medical errors, we should take Dr. Leape’s most important insight to heart:

We need to move from looking at errors as individual failures to realizing they are caused by system failures. This is the driving principle.

The ultimate irony of Sarah Palin’s “death panel” fabrication is that healthcare reform represents the best chance of reducing medical errors, while opposing healthcare reform virtually insures that medical errors will continue apace. No one should worry about being killed deliberately by a “death panel” but everyone should fear being killed accidentally by a medical error.