Review of “Medical Error—the Third Leading Cause of Death in the US” by Makary MA and Daniel M in BMJ 353: i2139, 2016
01 Jul 2017-Journal of Craniofacial Surgery (Ovid Technologies (Wolters Kluwer Health))-Vol. 28, Iss: 5, pp 1390
About: This article is published in Journal of Craniofacial Surgery.The article was published on 2017-07-01. It has received 131 citations till now. The article focuses on the topics: Cause of death.
Citations
More filters
TL;DR: This review synthesizes the evidence examining teams and teamwork in health care delivery settings in order to characterize the current state of the science and to highlight gaps in which studies can further illuminate the evidence-based understanding of teamwork and collaboration.
Abstract: Few industries match the scale of health care. In the United States alone, an estimated 85% of the population has at least 1 health care encounter annually and at least one quarter of these people experience 4 to 9 encounters annually. A single visit requires collaboration among a multidisciplinary group of clinicians, administrative staff, patients, and their loved ones. Multiple visits often occur across different clinicians working in different organizations. Ineffective care coordination and the underlying suboptimal teamwork processes are a public health issue. Health care delivery systems exemplify complex organizations operating under high stakes in dynamic policy and regulatory environments. The coordination and delivery of safe, high-quality care demands reliable teamwork and collaboration within, as well as across, organizational, disciplinary, technical, and cultural boundaries. In this review, we synthesize the evidence examining teams and teamwork in health care delivery settings in order to characterize the current state of the science and to highlight gaps in which studies can further illuminate our evidence-based understanding of teamwork and collaboration. Specifically, we highlight evidence concerning (a) the relationship between teamwork and multilevel outcomes, (b) effective teamwork behaviors, (c) competencies (i.e., knowledge, skills, and attitudes) underlying effective teamwork in the health professions, (d) teamwork interventions, (e) team performance measurement strategies, and (f) the critical role context plays in shaping teamwork and collaboration in practice. We also distill potential avenues for future research and highlight opportunities to understand the translation, dissemination, and implementation of evidence-based teamwork principles into practice. (PsycINFO Database Record
495 citations
TL;DR: Cancer care coordination approaches led to improvements in 81 % of outcomes, including screening, measures of patient experience with care, and quality of end-of-life care across the continuum of cancer care.
Abstract: According to a landmark study by the Institute of Medicine, patients with cancer often receive poorly coordinated care in multiple settings from many providers. Lack of coordination is associated with poor symptom control, medical errors, and higher costs. The aims of this systematic review and meta-analysis were to (1) synthesize the findings of studies addressing cancer care coordination, (2) describe study outcomes across the cancer continuum, and (3) obtain a quantitative estimate of the effect of interventions in cancer care coordination on service system processes and patient health outcomes. Of 1241 abstracts identified through MEDLINE, EMBASE, CINAHL, and the Cochrane Library, 52 studies met the inclusion criteria. Each study had US or Canadian participants, comparison or control groups, measures, times, samples, and/or interventions. Two researchers independently applied a standardized search strategy, coding scheme, and online coding program to each study. Eleven studies met the additional criteria for the meta-analysis; a random effects estimation model was used for data analysis. Cancer care coordination approaches led to improvements in 81 % of outcomes, including screening, measures of patient experience with care, and quality of end-of-life care. Across the continuum of cancer care, patient navigation was the most frequent care coordination intervention, followed by home telehealth; nurse case management was third in frequency. The meta-analysis of a subset of the reviewed studies showed that the odds of appropriate health care utilization in cancer care coordination interventions were almost twice (OR = 1.9, 95 % CI = 1.5–3.5) that of comparison interventions. This review offers promising findings on the impact of cancer care coordination on increasing value and reducing healthcare costs in the USA.
162 citations
TL;DR: It is proposed that the new estimate that medical error was to blame for 44 000–98 Thousands deaths each year in the US hospitals is very likely to be wrong and risks undermining rather than strengthening the cause of patient safety.
Abstract: One important reason for the widespread attention given to the 1999 US Institute of Medicine (IOM) report To Err Is Human 1 lie in its estimate that medical error was to blame for 44 000–98 000 deaths each year in the US hospitals. This striking claim established patient safety as a public concern, strengthened the case for improving the science underlying safety and motivated providers, policymakers, payers and regulators to take safety seriously. Some did express disquiet about the validity of the figures cited,2 including one of the principal investigators of the two studies that provided the data for these estimates.3
A decade and a half later, Makary and Daniel4 attribute an even higher toll to medical error: 251 454 deaths in US hospitals per year, making, they say, medical error the third-leading cause of death in the USA. Unsurprisingly, this claim generated widespread coverage in multiple media channels. It also ignited scientific controversy about the basis of the estimate and the role of mortality as a patient safety indicator (PSI). In this paper, we address this controversy and why it matters. We propose that the new estimate is very likely to be wrong. Not only is it wrong, it risks undermining rather than strengthening the cause of patient safety.
Though the paper by Makary and Daniel was widely cited as ‘a study’, it presented no new data nor did it use formal methods to synthesise the data it used from previous studies. The authors simply took the arithmetic average of four estimates since the publication of the IOM report, including one from HealthGrades,5 a for-profit company that markets quality and safety ratings, a report from the US Office of the Inspector General (OIG)6 and two peer-reviewed articles (table 1).7 ,8 The paper did not apply …
80 citations
TL;DR: It is crucial that nursing students develop confidence communicating with others to improve patient safety, particularly in the areas of challenging poor practice, and recognising, responding to and disclosing adverse events, including errors and near misses.
71 citations
TL;DR: Medication reconciliation including an ‘indication review’ for each prescription is an important aspect of patient safety, as the decreasing frequency of pill bottle reviews, suboptimal patient education, and poor communication between healthcare providers are factors that threaten patient safety.
Abstract: Case description : A 71-year-old female accidentally received thiothixene ( Navane ), an antipsychotic, instead of her anti-hypertensive medication amlodipine ( Norvasc ) for 3 months. She sustained physical and psychological harm including ambulatory dysfunction, tremors, mood swings, and personality changes. Despite the many opportunities for intervention, multiple health care providers overlooked her symptoms. Discussion : Errors occurred at multiple care levels, including prescribing, initial pharmacy dispensation, hospitalization, and subsequent outpatient follow-up. This exemplifies the Swiss Cheese Model of how errors can occur within a system. Adverse drug events (ADEs) account for more than 3.5 million physician office visits and 1 million emergency department visits each year. It is believed that preventable medication errors impact more than 7 million patients and cost almost $21 billion annually across all care settings. About 30% of hospitalized patients have at least one discrepancy on discharge medication reconciliation. Medication errors and ADEs are an underreported burden that adversely affects patients, providers, and the economy. Conclusion : Medication reconciliation including an ‘indication review’ for each prescription is an important aspect of patient safety. The decreasing frequency of pill bottle reviews, suboptimal patient education, and poor communication between healthcare providers are factors that threaten patient safety. Medication error and ADEs cost billions of health care dollars and are detrimental to the provider–patient relationship.
67 citations