Hospital Error Rate Calculations

Bob Latino blatino at RELIABILITY.COM
Thu May 5 23:35:55 UTC 2016


Thanks Bill

I suspect such studies don't exist, given the poor systems/non-existent systems to define, identify and track 'errors' in healthcare.

Why healthcare lags in this respect I have never understood.  They should be leading.

Can you elaborate on such systems that may exist in nuke, perhaps that healthcare may wish to explore for applicability?

Bob

Sent from my iPhone

On May 5, 2016, at 6:02 PM, DR WILLIAM CORCORAN <williamcorcoran at sbcglobal.net<mailto:williamcorcoran at sbcglobal.net>> wrote:

Perhaps my experience in other fields of endeavor does not apply to health care.

I observe that the vast majority of errors do not result in severe consequences. To have severe consequences it takes many errors, including errors in attending to errors that are identified.

I would expect that for every patient whose death involves error, there are perhaps a thousand or so patients whose cases involved error.

I would greatly appreciate links to any studies that speak to the ratio of fatal errors to all errors.

Take care,

Bill Corcoran


William  R. Corcoran, Ph.D., P.E.
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
William.R.Corcoran at 1959.USNA.com<mailto:William.R.Corcoran at 1959.usna.com>
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________________________________
From: Bob Latino <blatino at RELIABILITY.COM<mailto:blatino at reliability.com>>
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at list.improvediagnosis.org>
Sent: Thursday, May 5, 2016 12:49 PM
Subject: [IMPROVEDX] Hospital Error Rate Calculations

Forgive my naivety...

Exactly what is considered 'Medical Error'?
How and when is it recorded on the front lines?
How is it reported to entities that end up calculating these national 'medical error rates'?

WRT to this topic everyone always cites the 1999 IOM report and the 44k - 98k/yr death rate due to 'medical error'.  I recall in reading that report, in the fine print, that only included 'errors of commission' and not 'errors of omission' (which is likely greater).

Then in 2014 we hear the NPSF President Tejal Ghandi citing the 'hospital error' death rate of 400,000 at a Senate hearing.

Is a medical error and a hospital error the same thing?
Are these entities getting their data from the same sources?

Certainly these sources are only aggregating what is reported, so what is unreported could be a great deal more.

Now I hear on this forum that those error numbers 'do not include outpatient mistakes/deaths, nursing home mistakes/deaths or ambulatory care surgical centers', essentially meaning those stats are primarily acute care hospitals. Certainly if all of this is valid, medical and/or hospital error could easily be the number one killer in the U.S.

Do we really have a lock on what the actual magnitude of the problem is?  If we don't know the magnitude of 'hospital or medical error' we certainly can't carve out how much of that unknown is due to diagnosis error can we?

Robert J. Latino, CEO
Reliability Center, Inc.
1.800.457.0645
blatino at reliability.com<mailto:blatino at reliability.com>
www.reliability.com<http://www.reliability.com>

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