Professional Literature

Haynes, A. B., Weiser, T. G., & Berry, W. R. (2009). A surgical safety checklist to reduce morbidity and mortality in a global population. The New England Journal of Medicine, 360, 491-499. doi: 10.1056/NEJMsa0810119 

IDEA:  “We hypothesized that a program to implement a 19-item surgical safety checklist designed to improve team communication and consistency of care would reduce complications and deaths associated with surgery.”

CONCLUSION:  “The rate of death was 1.5% before the checklist was introduced and declined to 0.8% afterward (P=0.003). Inpatient complications occurred in 11.0% of patients at baseline and in 7.0% after introduction of the checklist (P<0.001).”

Hoyert DL, Xu JQ (2012). Deaths: Preliminary data for 2011. National vital statistics reports; vol 61 no 6. Hyattsville, MD: National Center for Health Statistics.

Table B details the number of deaths attributed to various causes.  Based on the most recent findings (James, 2013), preventable medical error is the third leading cause of death in the United States.

James, J. (2013). A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care. Journal of Patient Safety, 122-128.

“A lower limit of 210,000 deaths per year was associated with preventable harm in hospitals. Given limitations in the search capability of the Global Trigger Tool and the incompleteness of medical records on which the Tool depends, the true number of premature deaths associated with preventable harm to patients was estimated at more than 400,000 per year.”

Kohn, L., Corrigan, J., & Donaldson, M. (2000). To err is human: Building a safer health system. The National Academies Press.

“More commonly, errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them…Thus, mistakes can best be prevented by designing the health system at all levels to make it safer — to make it harder for people to do something wrong and easier for them to do it right.”

Levinson, D. R. Department of Health and Human Services, Office of Inspector General. (2010). Adverse events in hospitals: National incidence among medicare beneficiaries  (OEI-06-09-00090)

“An estimated 1.5 percent of Medicare beneficiaries experienced and event that contributed to their deaths, which projects to 15,000 patients in a single month.”

At a rate of 15,000 patients in a month, approximately 180,000 patients per year will have an adverse medical event contribute to their death.  The average 747 holds approximately 400 people, which means that if once crashed every day for a year, with no survivors, 146,000 people would die.

Mehtsun, W. T., Ibrahim, A. M., Diener-West, M., Pronovost, P. J., & Makary, M. A. (2013).   Surgical never events in the united states. Surgery, 153 (4), 465-472. doi: 10.1016/j.surg.2012.10.005

“The researchers, reporting online in the journal Surgery, say they estimate that 80,000 of these so-called “never events” occurred in American hospitals between 1990 and 2010 – and believe their estimates are likely on the low side.”