A fatal medication error

A 75-year-old woman died at Vanderbilt University Medical Center after receiving intravenous vecuronium, a drug that causes muscle paralysis, instead of Versed, a sedative.

Here’s what happened.

She had been recovering well from an intraparenchymal brain hematoma after a fall. While awaiting a full body positron emission tomography (PET) scan in the radiology department, the patient said she was anxious about being in the machine because she was claustrophobic.

A doctor ordered Versed 2 mg IV in the electronic medical record at 2:47 PM. Two minutes later, the pharmacy verified the order. The radiology department staff said they could not give the medication because they were very busy and the patient would need to be monitored.

So nurse A, who was functioning as the “help all” nurse was asked by the patient’s nurse, nurse B, to go to radiology and give the medication. At 2:59 PM, nurse A went to the automated dispensing cabinet (ADC) and searched for Versed in the patient’s profile. When she couldn’t find the drug listed, she selected the “override” setting to search for the drug. She entered the first two letters of the drug, VE, and clicked on the first medication that popped up.

More proof medical error is not the third leading cause of death

Over the last 20 years, estimates of the number of deaths caused by medical error have risen from 44,000-98,000 in 1999 [1] all the way up to 440,000 [2] and 251,000 [3]. Despite my efforts [4, 5] and those of others [6, 7] to debunk these guesses, they continue to permeate the lay press. If you Google “third leading cause of death,” you will find countless headlines naming medical error.

The papers claiming medical errors cause so many deaths assume that all complications result from errors and all complications are preventable. They extrapolate their final numbers from small studies not designed to or capable of estimating deaths due to medical error nationwide.

The most recent figures available from the National Hospital Discharge Survey [8] state that the number of hospital deaths dropped from 776,000 in the year 2000 to 715,000 in 2010. It is simply not plausible that 251,000 (35%) or 440,000 (61%) inpatient deaths are due to medical error.

A recent study [9] from Norway found that of 1000 consecutive in-hospital deaths reviewed, only 42 (4.2%) were judged to be probably (greater than a 50% chance) to definitely avoidable.

Causes of death among residents

What is the leading cause of death among residents in all specialties?

A. Accidents
B. Neoplasms
C. Suicide
D. Miscellaneous diseases

If you answered C, you were wrong. The correct answer is B, neoplasms. Suicide was the second most common cause, followed by accidents and miscellaneous diseases.

A study in Academic Medicine looked at resident deaths over a 15 year period and found that of the 381,614 individual physicians in ACGME training programs, 66 died of suicide. For the over 1.6 million person-years studied, the suicide rate for residents was 4.07 per 100,000 person-years—well below the figure of 13.07 per 100,000 years in the general population of people aged 25-34.

Residents in age groups 35-44 and 45-54 had suicide rates higher than the 25-34 group and higher than the rates of those in comparable general population age groups.

More suicides occurred during the first and second years of training and during the months of July through September and January through March. In my opinion, the months that deaths occurred in can be explained as follows. In the first three months of the academic year, residents in the first and second years may feel overwhelmed and subject to self-doubt—the so-called "impostor syndrome." By the time January and February roll around, it is mid-winter, and it seems like the year will never end.

Residents had a much lower rate of death from accidents, including those related to automobile crashes, than the general population.

The overall death rate from all causes was also lower for residents than the rate of the general population at 16.91 per 100,000 person-years and 105.4 per 100,000 person-years, respectively.

The authors were surprised that resident rates of suicide were lower than age- and gender-matched populations especially because suicide rates for medical students and practicing physicians are higher.

They concluded that suicide was probably the only area in which prevention strategies, such as a supportive environment and medical and mental health services, could reduce the death toll.

Program directors, faculty, and residents themselves should probably show heightened vigilance in the first and third quarters of the academic year particularly for first and second year trainees.

When bad research is not critically reported by journalists

Yesterday I posted a critical review of the study "Medical error—the third leading cause of death in the US."

I did not have time to address the media coverage of the paper, but fortunately the website HealthNewsReview did.

Their post started with "Seemingly all the major outlets carried the story, with headlines so alarming that they’d have any conscious hospital patient demanding an immediate discharge."

They called attention to headlines which included the word "now" such as these:

CBS: Medical errors now 3rd leading cause of death in U.S., study suggests
Washington Post: Researchers: Medical errors now third leading cause of death in United States
Nature World News: Medical Errors Now the Third Leading Cause of Mortality in U.S.

They pointed out that the headlines were similar to the title of a press release issued by the PR department at Johns Hopkins and that using "now" in the headline implies that the incidence of deaths caused by medical error has increased.

Why in-hospital deaths are not a good quality measure

You may be tired of hearing about the Surgeon Scorecard—the surgeon rating system that was recently released by an organization called ProPublica. Like many others, I have pointed out some flaws in it. You can read my previous posts here and here.

I had decided to stop commenting about it because enough is enough, but a recent paper in the BMJ raises a question about one of the criteria ProPublica used to formulate its ratings.

ProPublica defined complications 1) as any patient readmission within 30 days and 2) "any patient deaths during the initial surgical stay."

The authors of the BMJ paper randomly selected 100 records of patients who died at each of 34 hospitals in the United Kingdom. The 3400 records were reviewed by experts to determine whether a death could have been avoided if the quality of care had been better.

The number of patient records in which a death was at least 50% likely to have been avoidable was 123 or 3.6%.

There was a very weak association between the number of preventable deaths and the overall number of deaths occurring at each hospital. By two measures of overall hospital deaths, the hospital standardized mortality ratio and the summary hospital level mortality indicator, the correlation coefficient between avoidable deaths and all deaths was 0.3, not statistically significant.

From the paper: "The absence of even a moderately strong association is a reflection of the small proportion of deaths (3.6%) judged likely to be avoidable and of the relatively small variation in avoidable death proportions between trusts [hospitals]. This confirms what others have demonstrated theoretically—that is, no matter how large the study the signal (avoidable deaths) to noise (all deaths) ratio means that detection of significant differences between trusts is unlikely."

The Surgeon Scorecard was derived from administrative data. No individual analysis of patient deaths was undertaken. According to a ProPublica article discussing some key questions about their methodology, "As for deaths, we took a conservative approach and only included those that occurred in the hospital within the initial stay."

Maybe that wasn't such a conservative approach after all.

And maybe we need to rethink that 2013 paper claiming that medical error caused up to 440,000 deaths per year.