Deaths blamed on medical error each year enough to fill every se - Cleveland 19 News Cleveland, OH

Deaths blamed on medical error each year enough to fill every seat in FirstEnergy Stadium 6 times

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CLEVELAND, OH (WOIO) -

Medical errors are the third leading cause of death in the U.S., triggering more fatalities on average each year than respiratory disease and accidents combined, according to a recent study by John Hopkins University.


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At first its startling to hear the numbers—more American's are dying at the hands of medical professionals in the U.S. than many of the diseases and conditions those doctors and nurses are trained to treat.

The 2016 report by John Hopkins University, published in The BMJ -- a leading medical journal -- estimates at least 250,000 Americans die because of medical errors in our hospitals, doctors’ offices and labs every year.

Other studies show that number to be even greater. As many as 440,000 lives each year are lost to medical errors in America, according to a 2013 report published in the Journal of Patient Safety.

The eyebrow-raising numbers are sending shock waves through the medical community, and is the focus of a new documentary that recently debuted at the Cleveland International Film Festival, "To Err is Human."

THE PROBLEM

“Medical errors and preventable harm have been here the whole time, no one’s really talking about it,” said Mike Eisenberg, the film’s director.

A primary reason the epidemic of medical errors has gone under reported until recent years relates to how information on deaths are classified and collected in the U.S.

The Centers for Disease Control and Prevention collects information on the leading causes of death by way of death certificates. However, on those documents there is no way to indicate a medical error is what caused the patient’s death.

"To Err Is Human", released by Tall Tale Productions, borrows its name from a 1999 study published by the U.S. Institute of Medicine.

The watershed study concluded an average of 98,000 people died each year as a result of preventable medical errors. That number has at least doubled — possibly quadrupled, according to some studies, since that figure was released nearly two decades ago.

While both the initial report and subsequent documentary shine light on the number of fatal medical mistakes that are made, it should be noted there are a far greater number of non-fatal medical mishaps that happen each year in the U.S., often leaving the patients needing additional medical procedures or with life-altering injuries.

THE FILM

The documentary follows the heartbreaking story of the Sheridan family, hit not once but twice by preventable medical errors.

A missed diagnosis of Cal Sheridan’s newborn jaundice would lead to his significant cerebral palsy later in life.

The next medical miss for the family would be deadly.

Doctors appropriately diagnosed Pat Sheridan’s (Cal’s father) cancer, but the pathology was never communicated to the family or team of doctors.

What the Sheridans thought was only a benign tumor in Pat’s neck turned out to be malignant. He died at the age of 45.

The documentary also highlights slow changes revolutionizing the medical community that could shift the tide on the number of deadly medical mistakes that happen each year.

New programs are being developed to better train staff at major hospitals across the country and the medical community is beginning to borrow technology and procedures from industries that have earned the title of High Reliability Organizations.

These industries (think aviation and nuclear power) have installed a number of procedures and fail safes in their respective workflows to avoid catastrophes in environments where normal accidents could be expected because of inherent risk factors and the complexity of the job.

Congressional funding hurdles for national healthcare watchdog organizations, like the Agency for Healthcare Research and Quality (AHRQ), are also discussed at length in the film.

The father of the documentary’s director, John M. Eisenberg, MD, MBA, formerly headed the organization. He died prematurely at the age of 55.

Eisenberg, who has ties to Northeast Ohio as a former member of the Cleveland Indians organization and a graduate of Marietta College, decided to debut the film at the CIFF noting Cleveland’s role as a premiere city in the healthcare community.

WHAT’S BEING DONE IN CLEVELAND TO MAKE ME SAFER

“Cost and saving money is just the byproduct, but if you do the right thing for the patient that will all happen on its own,” said Abirammy Sundaramoorthy, M.D., Chief Medical Officer at University Hospitals' Conneaut Medical Center.

Sundaramoorthy was charged with heading up University Hospitals journey to becoming a High Reliability Organization in 2016 after the John Hopkins University report made headlines.

By late 2017, a culture-shifting training was in the works for the 20,000 employees across UH, from the CEO down to the custodial staff.

The biggest issue: How do you change industry culture so reporting a fellow doctor or a nurse’s mistake isn’t seen as backstabbing or career suicide?

“That's one of the biggest questions that comes up [during training]. 'You're teaching us about this reporting system, but will it be anonymous?’” said Sundaramoorthy.

At the start of 2018, Cleveland 19 News is told, all current staff members had completed the training and all incoming staffers are required to complete the course.

Sundaramoorthy stated that error reporting by staff has spiked since the start of 2018 and now “we’ve shifted our culture to the point where people are actually reporting their own errors or their own mistake.”

After the report is filled it’s reviewed by a panel of senior medical officers throughout the hospital. If it’s an equipment issue it’s flagged to be fixed. If it’s an issue of quality of care and may have injured the patient, the matter is looked into deeper to identify what went wrong in the hospital’s procedures.

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“The purpose of this is to find out where our process may have failed and put a fix in place” so another patient isn’t affect and potentially harmed by the same error.

Technology is also taking center stage in University Hospitals journey to reduce harm to patients with the introduction of their "digital rounding tool."

It’s essentially an in-house app allowing hospital supervisors the capacity to walk the halls of their facility, talk face-to-face with doctors, nurses, and staff and immediately address problems in their unit while reporting issues with a few taps on the app.

Despite changes being rolled out to better protect patients at hospitals across the country, like UH, personal injury and medical malpractice attorney Tim Misny argues patients must continue to hold healthcare professional accountable.

“Their motivation should be to treat people like they would like to be treated, not a business decision,” said Misny, “so the way to hurt them is to hurt their pocketbook, and that's how you force them to change policy.”

Sundaramoorthy echoes part of that message, pointing out this shift in how hospitals manage healthcare and safety ultimately shifts back to you, the patient, being more empowered and demanding better care.

“[Often] times patients feel like their questions may be stupid or the doctor doesn't have time for them. The reality is patients know things that we could never know within the course of a two- or three-hour interaction with them. Those little pieces of information are so incredibly important,” she said.

WHAT CAN I DO TO PROTECT MYSELF?

“To Err is Human” offers potentially lifesaving advice on how patients should better address and manage their own care.

“These doctors are doing the best they can, but they’ll do better if we’re engaged in our own care,” said Eisenberg.

Here are three tips highlighted in the film:

  • Ask more questions: If something doesn’t sound right or doesn’t make sense, don’t be afraid to speak up. You know your situation better than anyone else. Asking the ‘stupid question’ could change the course of your care.
  • Don’t be afraid to ask your doctor of nurse if s/he washed their hands: It can be awkward to challenge the doctor like this, but healthcare professionals either forgetting or just neglecting to wash their hands is the top way deadly infections are spread in hospitals.
  • Don’t go alone: It can be tough managing your care, especially if you’re dealing with an ongoing treatment. Bring along a close friend or family member so they can make sure nothing is missed and ask the doctor pressing questions when you might simply be overwhelmed by the process.

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