February 22, 2019

Better Reporting of Medical Errors

Barb MacFarlane

Author: Barbara A. MacFarlane, Partner

It has been reported in the past that ‘Medical Error’ is the third leading cause of death in the United States, behind heart disease and cancer, according to a study published by Drs. Makary and Daniel at John Hopkins. It is estimated at least 251,454 Americans die due to medical errors every year. The study goes on to say that medical error leading to patient death is under-recognized in many other countries, including UK and Canada. The failure of recognition seems to relate to how these deaths are recorded, or an inability of reporting systems to capture the medical errors. For example, the cause of death listed on a death certificate may state cardiac arrest. However, a medical mistake that led to the cardiac arrest is not noted.

The authors urge greater awareness to create preventative measures, and say:

Although we cannot eliminate human error, we can better measure the problem to design safer systems mitigating its frequency, visibility, and consequences…Currently, deaths caused by errors are unmeasured and discussions about prevention occur in limited and confidential forums, such as a hospital’s internal root cause analysis committee or a department’s morbidity and mortality conference. These forums review only a fraction of detected adverse events and the lessons learnt are not disseminated beyond the institution or department.

Transparency about medical mistakes, can save lives: “More appropriate recognition of the role of medical error in patient death could heighten awareness and guide both collaborations and capital investments in research and prevention” the authors say.

Survey Summary Points

  • Death certificates in the US, used to compile national statistics, have no facility for acknowledging medical error.

  • If medical error was a disease, it would rank as the third leading cause of death in the US.
  • The system for measuring national vital statistics should be revised to facilitate better understanding of deaths due to medical care.

A full copy of the survey appears in the British Medical Journal.

As seen in past media coverage, lack of transparency about medical errors has also been a long-standing issue in Canada. When a loved one dies or suffers from complications due to medical error, family members often do not have access to information about the full circumstances behind the situation. Not only are these events emotionally devastating, they can also be financially crippling. Often those injured or loved ones are often left with a lot of questions about what went wrong. For example, would earlier care have made a difference or could the injury have been avoided with better medical management. Sometimes the only way to get access to information about medical errors is through the legal system. Full accountability for medical mistakes can affect changed for improved medical care and reduce medical errors.

This article was originally posted as a blog on the Ontario Trial Lawyers’ Association’s website.