Medical error is the third leading cause of death in the United States, after heart disease and cancer, according to findings published this month in the British Medical Journal.
As such, medical errors should be a top priority for research and resources, say authors Martin Makary, MD, MPH, professor of surgery, and research fellow Michael Daniel, from Johns Hopkins University School of Medicine in Baltimore, Maryland.
But accurate, transparent information about errors is not captured on death certificates, which are the documents the Centers for Disease Control and Prevention (CDC) uses for ranking causes of death and setting health priorities. Death certificates depend on International Classification of Diseases (ICD) codes for cause of death, so causes such as human and system errors are not recorded on them.
And it's not just the US. According to the World Health Organization, 117 countries code their mortality statistics using the ICD system as the primary health status indicator.
The authors call for better reporting to help capture the scale of the problem and create strategies for reducing it.
Cancer and Heart Disease Get the Attention
"Top-ranked causes of death as reported by the CDC inform our country's research funding and public health priorities," Dr Makary said in an university press release. "Right now, cancer and heart disease get a ton of attention, but since medical errors don't appear on the list, the problem doesn't get the funding and attention it deserves."
He adds: "Incidence rates for deaths directly attributable to medical care gone awry haven't been recognized in any standardized method for collecting national statistics. The medical coding system was designed to maximize billing for physician services, not to collect national health statistics, as it is currently being used."
The researchers examined four studies that analyzed medical death rate data from 2000 to 2008. Then, using hospital admission rates from 2013, they extrapolated that, based on 35,416,020 hospitalizations, 251,454 deaths stemmed from a medical error.
That number of deaths translates to 9.5% of all deaths each year in the US — and puts medical error above the previous third-leading cause, respiratory disease.
In 2013, 611,105 people died of heart disease, 584,881 died of cancer, and 149,205 died of chronic respiratory disease, according to the CDC.
The new estimates are considerably higher than those in the 1999 Institute of Medicine report "To Err Is Human." However, the authors note that the data used for that report "is limited and outdated."
Strategies for Change
The authors suggest several changes, including making errors more visible so their effects can be understood. Often, discussions about prevention occur in limited and confidential forums, such as a department's morbidity and mortality conference.
Another is changing death certificates to include not just the cause of death, but an extra field asking whether a preventable complication stemming from the patient's care contributed to the death.
The authors also suggest that hospitals carry out a rapid and efficient independent investigation into deaths to determine whether error played a role. A root cause analysis approach would help while offering the protection of anonymity, they say.
Standardized data collection and reporting are also needed to build an accurate national picture of the problem.
Jim Rickert, MD, an orthopedist in Bedford, Indiana, and president of the Society for Patient Centered Orthopedics, told Medscape Medical News he was not surprised the errors came in at number 3 and that even those calculations don't tell the whole story.
"That doesn't even include doctors' offices and ambulatory care centers," he notes. "That's only inpatient hospitalization resulting in errors."
"I think most people underestimate the risk of error when they seek medical care," he said.
He agrees that adding a field to death certificates to indicate medical error is likely the way to get medical errors the attention they deserve.
"It's public pressure that brings about change. Hospitals have no incentive to publicize errors; neither do doctors or any other provider," he said.
However, such a major step as adding error information to death certificates is unlikely if not accompanied by tort reform, he said.
Still, this study helps emphasize the prevalence of errors, he said.
Human error is inevitable, the authors acknowledge, but "we can better measure the problem to design safer systems mitigating its frequency, visibility, and consequences."
They add that most errors aren't caused by bad doctors but by systemic failures and should 'not be addressed with punishment or legal action.
Dr. Cinque: So, what do they mean by "systemic" errors as opposed to doctor error? Do they mean that the doctor followed the standard protocol but the protocol was wrong? That's what it sounds like to me.
First, note that this has been reported before that medical errors are killing people on a grand scale. I mean: it has been known for decades. And they said then that steps were going to be taken, etc. etc. to reduce the medical carnage, but obviously, it hasn't worked. Second, medical deaths are still being grossly underreported. Take heart disease, for instance, the leading killer. If a person dies from the adverse effects of medications for heart disease, such as calcium channel blockers which are dangerous because they can trigger heart attacks, it's likely to be called a death from heart disease rather than heart disease treatment.
I'll admit that my perspective is very bleak. I think that most of medical treatment is killative. Leastways, most of it is harmful. Most of it amounts to suppressive, symptomatic, pharmaceutical tinkering which adds a new abnormality to the ones you've already got- complicating your condition, even if in some ways it seems better or looks better. They are not making you healthier; they are just making your disease manifest differently as you continue going downhill.
A good example are diuretics which are very widely prescribed but rarely do anybody any good. You're better off living with whatever fluid retention you have than trying to get rid of it forcibly that way. Better yet, take some constructive actions with diet, salt restriction, weight loss, exercise, supplements, and perhaps fasting to see if you can get it to resolve naturally and spontaneously through actual biological improvement rather than forcing measures. What's so terrible about that? Remember, patience is a virtue. You start doing the right things, and then you give it time. There is no need to resort to anything reckless and drastic.
This whole thing is complicated by the fact that there are areas in Medicine in which they do do valuable and beneficial things, such as surgery for cataracts, giving Metformin to Type II diabetics, antibiotics when necessary, and hormone replacement when indicated, especially when they are bio-identical. And I have no doubt that great work is being done with stem cells, and more is to come. But, none of that changes the fact that most of modern medical treatment is just disruptive pharmaceutical tinkering, which is hurting people and sometimes killing them. As a percentage, there isn't that much good in Medicine, and most of it should be avoided.
Does that seem radical? Well, I'm sorry, but it's true.
I am republishing here the April newsletter of Dr. Uffe Ravnskov. Dr. Ravnskov is a Swedish physician, a nephrologist (kidney specialist) and internist. And for many years, he has been at war with the medical establishment over cholesterol and use of cholesterol-lowering drugs, particularly statins. The evidence is very strong that statins do no prolong life, and they may even shorten life. I'm sure that Dr. Ravnskov would say that statins are the biggest medical scam of all time- and I agree with him. So, here is his latest newsletter. Be glad to know about this extremely knowledgeable and immensely competent physician, Dr. Uffe Ravsnkov.
In a recent Danish paper published in European Heart Journal the authors claimed, that negative statin-related news stories decrease statin persistence and increase myocardial infarction and cardiovascular mortality. It was based on the fact, that early statin discontinuation by some of more than 800,000 Danish statin-treated people was associated with the number of negative statin-related news stories published in the media between 1995 and 2010., and that 1.1% more of those with early statin discontinuation had died after 10 years of follow-up compared with those who continued.
A more reasonable explanation is that the statin-treated individuals learned that their many unpleasant symptoms were caused by the statins, because most adverse effects do not appear immediately. Very often they develop several weeks or months after the start of the treatment. As the side effects of almost all drugs appear immediately, neither the “patient” or the doctor realize that the late statin side effects are caused by the drug. The muscular problems, the mental disturbances and the decrease of sexual potency, the most common side effects, are therefore seen as a result of of increasing age.
An interesting observation is that the heart mortality difference of 1.1% is what those who continued their treatment won after 10 years of treatment. This is much less than reported from the statin trials. In the first statin trial 4S for instance, the difference between the statin and then placebo group as regards heart mortality was 2.5% after about five years of treatment. Notary impressive, but more than four times as much as in this paper.
Furthermore, there was not a word about total mortality in the paper. The only reason for excluding this information is of course, that either there was no difference, or that those, who stopped statin treatment lived longer than those who continued. It was not possible either for a Canada Free Press journalist to get this information from Børge Nordestgaard, one of the authors and head of the department, where the study was performed. He just answered the following: We probably could have looked at all-cause mortality. What I thought would have meaning for people that are interested in this field was myocardial infarction and cardiovascular death. Those are the two major endpoints that you look for when trying to prevent cardiovascular disease.
Aren´t the main interest of people on preventive medicine to prolong their life?
In an interview in the Danish newspaper Politiken, Nordestgaard declared that people, who stop their statin treatment have a 26% increased risk of a heart attack and 18% higher risk to die from a cardiovascular disease compared with those, who continue the treatment.
What explains his misleading words may be that he has strong economical links to the drug industry. In the section Conflicts of interest you can read the following: B.G.N. has received consultancy fees and/or lecture honoraries from Astra Zeneca, Pfizer, Merck, Amgen, Sanofi, Regeneron, Omthera, Dezima, ISIS Pharmaceuticals, Aegerion, Fresenius, B. Braun, Kaneka, Lilly, Kowa, and Denka Seiden.
Much evidence has shown that there is little benefit from statin treatment, if any at all. In my previous newsletter for instance, I told you about the Danish study, where the authors had calculated how may years you are able to prolong your life by statin treatment. What they found was that on average you can only prolong it by a few days.
Recently a research group from Italy, the UK and Sweden published a study in BMJ Open about the trends of statin use and heart mortality between 2000 and 2012 in 12 European countries. In all of the countries statin treatment has increased and heart mortality had decreased, apparently a support of statin treatment. However, there was no association between the degree of statin increase and the degree of mortality lowering between the countries. In Germany, for instance, statin treatment had increased by 54% during these years and heart mortality had decreased by 85%, whereas in Portugal statin treatment had increased by102%, whereas heart disease had decreased by only 41%.
As I have told you before, the directors of the statin trial do not allow access to the primary data. This has raised much criticism and a campaign, backed by the British Queen´s former doctor Sir Richard Thompson calling for urgent public enquiry into drugs firms' 'murky' practices. You can read more about that in in Daily Mail, in Sunday Express and in The Western Australia
In 2005 new, stricter regulations were introduced in the conduct and publication of randomized controlled trials. Since then the results of all statin trials have been minimal compared to those published before 2005 You can read more about that in a paper published in Expert Review of Clinical Pharmacology by Professor Harumi Okuyama and his co-authors; in a paper in Journal of Controversies in Biomechanical Research by Michel de Lorgeril and Mikael Rabaeus, and in Sunday Express. The authors of the two scientific journals are no amateurs; most of them are members of THINCS and de Lorgeril was the first who demonstrated the benefits of the Mediterranean diet.
Uffe Ravnskov, MD, PhD, independent investigator
A new study out of Sweden and published on Medscape, which is an online magazine for doctors, reported that nonsmokers who stayed out of the sun had a life expectancy similar to that of smokers who soaked up the most rays. Hence, not getting sufficient sunlight is as dangerous and life-shortening as smoking. The study involved nearly 30,000 Swedish women over 20 years.
This indicates that avoiding the sun "is a risk factor for death of a similar magnitude as smoking," write the authors of the article, published March 21 in the Journal of Internal Medicine. Compared with those with the highest sun exposure, life expectancy for those who avoided sun dropped by 2.1 years.
Pelle Lindqvist, MD, of Karolinska University Hospital in Huddinge, Sweden, and colleagues found that women who seek out the sun were generally at lower risk for cardiovascular disease (CVD) and such diseases as diabetes, multiple sclerosis, and pulmonary diseases, than those who avoided sun exposure.
And one of the strengths of the study was that results were dose-specific — sunshine benefits went up with the amount of exposure.
The researchers acknowledge that longer life expectancy for sunbathers seems paradoxical to the common thinking that sun exposure increases risk for skin cancer.
"We did find an increased risk of.skin cancer. However, the skin cancers that occurred in those exposing themselves to the sun had better prognosis," Dr Lindqvist said.
Some Daily Exposure Important for Health
Given these findings, he told Medscape Medical News, women should not overexpose themselves to sun, but underexposure may be even more dangerous.
"We know in our population, there are three big lifestyle factors that endanger health: smoking, being overweight, and inactivity," he said. "Now we know there is a fourth — avoiding sun exposure."
Sweden's restrictive guidance against sun exposure over the past 4 decades may be particularly ill-advised, the study finds, in a country where the maximum UV index is low (< 3) for up to 9 months out of the year.
Use of sunscreen is also widely misunderstood in the country and elsewhere, Dr Lindqvist said.
"If you're using it to be out longer in the sun, you're using it in the wrong manner," he said. However, "If you are stuck on a boat and have to be out, it's probably better to have sunscreen than not to have it."
Women with more pigmentation would be particularly well-served to stop avoiding sunshine, he said, adding that many people in India, for instance, follow guidelines like those in Sweden to avoid sun year round.
And because melanomas are rare among women with darker skin, benefit goes up in those populations when weighing sun exposure's risk against benefits, Dr Lindqvist said.
Age and Smoking Habits
The researchers studied sun exposure as a risk factor for all-cause mortality for 29,518 women with no history of malignancy in a prospective 20-year follow-up of the Melanoma in Southern Sweden cohort.
The women were recruited from 1990 to 1992 when they were 25 to 64 years old. Detailed information was available at baseline on sun-exposure habits and potential confounders such as marital status, education level, smoking, alcohol consumption, and number of births.
When smoking was factored in, even smokers at approximately 60 years of age with the most active sun-exposure habits had a 2-year longer life expectancy during the study period compared with smokers who avoided sun exposure, the researchers note.
.Role of Vitamin D Still in Question
The results add to the longstanding debate on the role of vitamin D in health and the amount of it people need, but this study doesn't resolve the question.
"Whether the positive effect of sun exposure demonstrated in this observational study is mediated by vitamin D, another mechanism related to ultraviolet radiation, or by unmeasured bias cannot be determined. Therefore, additional research is warranted," the authors write.
Dr. Cinque: Even the role of sunlight in causing skin cancer is not fully understood because it is not uncommon for people to develop skin cancers in areas which have not been over-exposed. Likewise, there are plenty of areas which, which for some people, are chronically over-exposed- say the arms of a fisherman- where the incidence of skin cancers doesn't correlate. Protecting the skin from too much sun exposure is definitely a good idea, apart from cancer, because we know it ages the skin and damages it. But, there are plenty of people who want to avoid the sun completely, and that is wrong. The sun's ultraviolet has a powerful anti-cancer effect which seems to work against every kind of cancer except skin cancer. And yes, skin cancer can be deadly, but caught early, it is about the easiest cancer to treat. Here's a good rule of thumb: if the sun exposure you are are getting is causing frank, visible tanning, then you're getting too much sun. The frank, visible tanning is a reaction to too much sun. And here's another good rule: if you want to protect your face all the time, it's fine. You are not going to suffer if that small part of your body doesn't get exposed to the sun. But, find large, broad areas of yourself that you can expose directly to effective sunlight for 10 or 15 minutes at a time. There is more danger if you don't than if you do.