Iatrogenic

[riddler 0]

Word of the day. Iatrogenic means "induced inadvertently by a physician or surgeon or by medical treatment or diagnostic procedures". A significant number of deaths in the U.S. each year are caused by mistakes made by doctors in hospitals. How big is this problem?

According to a recent report by HealthGrades, iatrogenic deaths accounted for 195,000 American lives in each of the years 2000, 2001, and 2002. That places it in in the top three leading causes of death.

According to JAMA (Journal of the American Medical Association, arguably, the most noted health care publication in this country), the leading causes of death in 2000 were tobacco (435,000 deaths; 18.1% of total US deaths), poor diet and physical inactivity (400,000 deaths; 16.6%), and alcohol consumption (85,000 deaths; 3.5%).

If one is to believe these statistics, then the third leading cause of death in the US, is in fact, iatrogenic death. Why don't you see this number in the JAMA results? Could it be that the medical profession doesn't want you to know that they make mistakes? I think every doctor will tell you that they make mistakes. But what if the mistakes are so prevalent as to become the third leading killer in the US? Would JAMA be just as hard on themselves as they are on the tobacco and alcohol industries?

Moreover, many experts are looking hard at the numbers, and believe the statistics to be underestimated. These numbers only account for deaths in-hospital. They do not account for outpatient treatments resulting in death, or adverse drug reactions from even properly prescribed drugs.

It's tempting to start talking about alternatives to modern medicine and modern healthcare at this point, but I will refrain Just getting the American people to become aware of this problem, and the AMA to admit to it would be a huge step forward.

Trapped on the surface of a sphere. XKCD

[Shotgun 1]

Quote

According to a recent report by HealthGrades, iatrogenic deaths accounted for 195,000 American lives in each of the years 2000, 2001, and 2002. That places it in in the top three leading causes of death.

According to JAMA (Journal of the American Medical Association, arguably, the most noted health care publication in this country), the leading causes of death in 2000 were tobacco (435,000 deaths; 18.1% of total US deaths), poor diet and physical inactivity (400,000 deaths; 16.6%), and alcohol consumption (85,000 deaths; 3.5%).

If one is to believe these statistics, then the third leading cause of death in the US, is in fact, iatrogenic death.

If one is to believe these statistics, then going to the doctor is more dangerous than alcohol consumption... So I think I'll cancel that appointment that I have with my doctor today and get drunk instead.

[wmw999 2,150]

One thing I'd wonder about would be how many of those were from judgement calls for already-very-sick people. If you're sick, you're more vulnerable.

That said, the whole day surgery thing is in part to avoid people being in the hospital and exposed to all those different germs. It's not all about saving money for the insurance companies (although they do like that side effect).

Hospitals do think about it, too -- my BF's sister is a nurse specializing in hospital-borne infections.

Wendy W.

There is nothing more dangerous than breaking a basic safety rule and getting away with it. It removes fear of the consequences and builds false confidence. (tbrown)

[riddler 0]

Quote

Hospitals do think about it, too

I believe that everyone in the medical community thinks about it. I don't believe that anyone admits to it. Why doesn't JAMA publish the numbers? Only when the AMA admits to a problem publicly, and with solid statistical evidence, will they take the needed measures to correct it.

Trapped on the surface of a sphere. XKCD

[kallend 1,651]

But...but... we have the best healthcare system in the world.

...

The only sure way to survive a canopy collision is not to have one.

[gemini 0]

Makes you wonder what some of the other countries stats look like.

Blue skies,

Jim

[GeorgiaDon 340]

Does iatrogenic = mistake? Not always. How about:
If a doctor doesn't put in this stent to open this blocked blood vessel the patient will die, for sure. If the doctor does put in the stent, there is a 2% chance that the stent will cause a clot and the patient will die.
Doctor puts in stent.
Patient dies.
Did the doctor make a mistake? Do we really want doctors to avoid any and all procedures that have some risk, preferring to be able to say "well we let nature take it's course"?
Think of all the unemployed lawyers that would generate!

Don

_____________________________________
Tolerance is the cost we must pay for our adventure in liberty. (Dworkin, 1996)
“Education is not filling a bucket, but lighting a fire.” (Yeats)

[peregrinerose 0]

Iatrogenic does not mean mistake. And iatrogenic infection is definitely well known and no secret in the medical community, at least as far as I have seen.

As someone else mentioned, these people are already sick, already immunocompromised, they can not fight off any bacteria at all, often their own natural bacteria, so any strain of bug that they don't already have antibodies for can cause serious problems.

It doesn't have to be from a mistake by anyone. It is impossible to remove every microorganism from every surface in a patients room short of putting them in a bubble.

During the civil war, over 30% of amputees died of iatrogenic infection. I bet the rate is a lot lower now. Medicine is always looking for ways to prevent this.

Do or do not, there is no try -Yoda

[billvon 2,435]

>the third leading cause of death in the US, is in fact, iatrogenic
> death. Why don't you see this number in the JAMA results? Could
>it be that the medical profession doesn't want you to know that they
> make mistakes?

The most common cause of death in skydiving is failure of the parachute to slow you down sufficiently before impact. Why don't you see this in incident reports? Could it be that USPA gets lots of support from parachute manufacturers, and the manufacturers don't want you to know that their gear is killing people? Call 60 Minutes!

[riddler 0]

Quote

As someone else mentioned, these people are already sick, already immunocompromised, they can not fight off any bacteria at all, often their own natural bacteria, so any strain of bug that they don't already have antibodies for can cause serious problems.

It's fair to say every patient in a hospital is already sick. But "already sick" or "pretty old" or "getting ready to die anyway" are not categories of death in the JAMA Journal. If a 79 year old man with lung cancer dies, they don't get lumped into the statistic of "already dying"; they get lumped into "tobacco". But if that same man dies because he was mistakenly given an appendectomy, he still gets lumped into "tobacco".

I see this as an issue in that the medical community does not recognize that they are a big part of the problem. They think "these patients are sick anyway, and we are only trying to help them." But they make errors. A significant amount of errors to compromise the third leading cause of death.

And they don't admit to it. JAMA produces smaller, more individual assessments, such as this one

Quote

We studied the contribution of iatrogenic illness to cardiac arrest among patients hospitalized in 1981 in a university teaching hospital. During this 1-year period, 28 (14%) of 203 arrests in which resuscitation was attempted followed an iatrogenic complication. Seventeen (61%) of the 28 patients died.

But they don't want to make an assessment on the grand scale - they type that gets reported in the media - to show that their mistakes cost 195,000 lives each year. For me, it's not that hard to do. Just step up and say "we make mistakes; enough to be an epidemic in this country. We're going to try to fix that". Even GWB did that after Katrina. Why does the medical community want to tone down their responsibility?

Quote

Iatrogenic does not mean mistake.

Edit to add: for the purposes of this article, iatrogenic DOES mean mistake. From the article:

Quote

Of these sixteen, the mortality associated with two, failure to rescue and death in low risk hospital admissions, accounted for the majority of deaths that were associated with these patient safety incidents.

Trapped on the surface of a sphere. XKCD

[Lindsey 0]

One example.... I have a patient right now who came into the ER on Monday with bilateral pulmonary emboli--blood clots sent to her lungs from her leg. She also has emboli to her liver, and her liver enzymes are through the roof. The ONLY way to save her life is to anticoagulate her blood--try to dissolve the clots. Well now (because of the anticoagulation) she is losing blood through her GI tract. She has also had a stroke in the past and is at risk for another one because of her anticoagulation. BUT without it, she'll die of her PE. So we may just kill her with Heparin--hopefully not--but without it she's gonna die anyway.

There are many, many such examples. Nobody's gonna hide that from you. There are also mistakes, and I HOPE that most doctors wouldn't hide those either--it's better not to. I honestly believe, though, that the former are far more numerous than the latter. I could go through my patient list of the last month and give several good examples. I haven't (to my knowledge) killed anyone yet.

--
A conservative is just a liberal who's been mugged. A liberal is just a conservative who's been to jail

[riddler 0]

Quote

One example....

Your example wouldn't fall into the category of iatrogenic. Making the best choice out of a lot of poor choices would not qualify. However, deciding to administer Heparin and administering Hexamethylenetetramine by mistake, leading to her death would compromise iatogenic.

This article isn't about best guesses and near misses. It's about overt errors that could have been prevented. I encourage reading the article:

Quote

Patient-safety incidents with the highest rates per 1,000 hospitalizations were failure to rescue, decubitus ulcer and postoperative sepsis, which accounted for almost 60 percent of all patient-safety incidents that occurred.

And I don't think a doctor would try to hide that if it did happen. This isn't a criticism of doctors. It is a criticism of the medical culture and community. I'm not even advocating changing anything at this point. I'm only advocating that the AMA needs to take responsibility for their actions by very publicly making the statement, and not just discussing it within smaller circles. At the point that they do (if ever), then they can address it and decide the most appropriate actions to take.

Trapped on the surface of a sphere. XKCD

[diverborg 0]

Quote

But...but... we have the best healthcare system in the world.

I lived in Germany for a little while on a govt contracted job. While there I got really sick with bigassoreonmypenislitis or something like that. I had to go to a German doctor. It was awful, he drove a volvo and they didn't have any pretty pictures on the walls. I couldn't even find a field&stream in the waiting room. I will never use a foreign healthcare system again.

[peregrinerose 0]

I read over the article again. It lists under 'mistake' post operative sepsis. Every time there is any form of cut in the body, there is a risk of infection. That's why you put neosporin on a skinned knee. Cut someone open that is immunocompromised, and despite antibiotics, they can still get an infection from even a couple bacteria that get in the wound from their own skin. It is not a medical mistake, it is a well established risk of a surgical procedure.

The article was extremely misleading in nature. For example. If I have a patient with an embedded hunk of metal in the cornea, I take it out to prevent it from causing recurrent corneal erosion, rusting in the cornea and/or causing permanent vision loss. Because it is embedded, there is no gaping wound, but it needs to be removed. So I take out the metal, put the patient on strong antibiotics, and follow them daily until the problem is resolved. I have done everything right, but that patient may still develop what would technically be an iatrogenic infection with visual morbidity. Exactly what in my treatment plan was mistaken? Nothing.

Iatrogenic infection is something taken very seriously by docs, and every effort is made to control for it. However it is impossible to get rid of every single fungal or bacterial cell in an entire operating room. Particularly in immunocompromised patients, antibiotics may just not be enough to fight off infection.

My grandmother recently died of iatrogenic sepsis, so this is personal to me. However, her doctors did do everything right, her body just could not fight off the bacteria producing the toxins.

Medical mistakes are made. That is not in dispute. Iatrogenic problems occur, also not in dispute. However iatrogenic problems are not in many situations caused by any form of medical mistake.

Jen

Do or do not, there is no try -Yoda

[riddler 0]

I don't think this article, or any statistical survey is complete and accurate. What if it's not? What if you factored out - say half of the deaths - just to be on the safe side. (Factor of 2, can you tell I'm an engineer? ). Many physicians are claiming these numbers are already on the low side, but we'll go the other way cut them in half. That would eliminate iatrogenic sepsis completely, if you wish, even though many of those deaths are still preventable.

What then? Iatrogenic deaths would compromise a little under 100,000, and still be the third leading cause of death. That describes the magnitude of the problem.

If this problem is so large, why doesn't the AMA admit to it? Why don't they publish as the third leading cause, before alcohol? Doctor's have real choices to make, including the life and death of patients, and they have the courage to do that. That is the responsibility they take. Why doesn't the community have the courage and the moral responsibility of admitting to their mistakes as a whole?

Trapped on the surface of a sphere. XKCD

[billvon 2,435]

>don't they publish as the third leading cause, before alcohol?

Say an alcoholic comes in. He is in end-stage liver failure. They try a transplant, but he is so immunocompromised that he becomes septic and dies. Was that an alcohol related death or an iatrogenic death?

[riddler 0]

Would that comprise a iatrogenic death? Nowhere in the article do they say that all septic deaths are iatrogenic. But what if they were? What if you eliminated all septic deaths from the numbers? The third leading cause of death would still be iatrogenic.

The first cause is listed as failure to rescue. If that person were elderly, and it looked like they were on the cusp anyway, and a doctor decided to make them last in the triage, would we not count that as a failure? I would. And I would encourage the AMA to list it as a failure, rather than throw it into some disease-related category.

Trapped on the surface of a sphere. XKCD

[Lindsey 0]

What do they mean by "failure to rescue?" If a person codes in the hospital then they code. There is no consideration of age or illness, only of their DNR status. Same with visits to the ER. People are triaged based on the severity of their illnesses, not on issues like age and liklihood to have a long life. Where that's not the case....I'd be appalled.

I guess I'm going to have to read this article, because things like "failure to rescue" don't mean much to me. That could mean many things that either delayed resussitation or caused a resussitative effort to fail. Things I can think of that might be considered iatrogenic are (another one that happened to me recently) not having appropriate equipment handy (intubation equipment, for example) at particular locations in the hospital, or a patient who is not on monitors arresting, delaying a code and necessary care. Or (another example from first-hand experience), a person having a relatively rare, but serious, reaction to a medication that caused a life-threatening complication for him. However--without antihypertensive medication (one of which his reaction was to) he would have a HIGH liklihood of a bad outcome. AND...even though he's one of those people without much of a future, you should have seen the rapid response to his collapse. It was impressive.

There is such a wide gamut of things that happen in a hospital or other medical setting that one could say, in some way, lead to a person's death. Where you draw the cut-off for what's iatrogenic and what's not is VERY subjective, as is clear from people's posts here. I think it's important for the AMA to publish these kinds of statistics so that we can improve what we do in healthcare....and I know that, for the most part, healthcare providers strive to provide care without doing harm and make doing so a top priority. That's why we study long hours, and review our cases with our peers, and learn to critique our work in a very detailed and thorough way.

Thinking through the patients that I have been involved with who have died over the last few months...I don't think that physicians were to blame for any of their deaths, though I'm certain that there have been some who died as a result of their treatment--like the lady I mentioned earlier with pulmonary emboli is at risk because of my current treatment. These would fit someone's criteria for iatrogenic death.... It's when the people in the general public who, with little real knowledge of medicine, want to grab those statistics to cause controversy that they stop being helpful, imho.

--
A conservative is just a liberal who's been mugged. A liberal is just a conservative who's been to jail

[riddler 0]

Quote

I think it's important for the AMA to publish these kinds of statistics so that we can improve what we do in healthcare....

Exactly what I'm saying. I wouldn't argue with anything you just wrote. But where are the statistics? They're not in any leading articles. They're not even in the list of leading causes of death:

Quote

The leading causes of death in 2000 were tobacco (435 000 deaths; 18.1% of total US deaths), poor diet and physical inactivity (400 000 deaths; 16.6%), and alcohol consumption (85 000 deaths; 3.5%). Other actual causes of death were microbial agents (75 000), toxic agents (55 000), motor vehicle crashes (43 000), incidents involving firearms (29 000), sexual behaviors (20 000), and illicit use of drugs (17 000).

One source says 195,000 deaths a year, and another doesn't even mention it? Maybe JAMA thinks it's less than 17,000/year. I believe it's not even on JAMA's list, and I seriously doubt it ever will be.

I don't believe it's a conspiracy. I believe it's financial. When you go to a dropzone, they don't post numbers on the bulletin board about how many people have died there. When you go to get your car fixed, they don't tell you how many times they've broken cars. When you go to a hospital, you don't want to sit in the waiting room or hospital bed and read a JAMA article about how hospitalization is a leading cause of death. But I also believe that doctors have a higher calling than dropzones and auto repair facilities, and should be held to a higher moral standard. That's just me. Maybe others think it's better to keep them like a corporation and focus on making money.

Trapped on the surface of a sphere. XKCD

[billvon 2,435]

>What if you eliminated all septic deaths from the numbers?

That's just one category that you eliminate. Peregrinerose and Lindsey, both of whom know a lot more about medicine than I do, listed a few more. Again, I think it's like claiming that parachutes kill people by not slowing them down before impact. It's clearly the parachute's fault! Why the coverup?

Most skydivers will reply that that's misleading; the parachute is doing exactly what you tell it to do, it's packing error, the parachute didn't really fail blah blah blah. But a casual reader would have to know a fair bit about skydiving before he understood that.

[Lindsey 0]

It's not even financial, I don't think. There are so many factors involved that it's really difficult to make the categorizations that you're talking about. If the AMA has put some effort, somehow, into achieving this, then it's hard for me to imagine it having any real validity or reliability. What they DO publish, though, I hope would be meant for us who practice medicine to improve what we do, and I'd imagine that it would be very liberal in what it categorizes as "iatrogenic," so that we will continue to raise our bar. It bothers me when people grab our own critiques of our work with ulterior motives.

I think about the logistics of putting such statistics together. How was it done??? Where did the data come from? I guess I'll have to find this study in my free time.

Edited to add: Oh MY! I just re-read your original post. It was some "HealthGrades" or other publication that you got this from???? I thought that it was in JAMA....now I'm laughing both at myself for giving this as much of my time as I did and (sadly) at the fact that a lot of people will read such sources and take what they print as credible....

--
A conservative is just a liberal who's been mugged. A liberal is just a conservative who's been to jail

[lawrocket 3]

Quote

I don't believe that anyone admits to it.

Strangely enough, I haven't been to any hospitals where the doctors, nurses, etc. did not wash their hands, wear gloves, wear smocks, etc. It turns out that "Sterile technique" is utilized to prevent iatrogenic illnesses.

While we're at that list of the causes of death, you listed tobacco as the number one killer. Tobacco doesn't kill many people. The cancer, heart attacks and CVA's that tobacco cause do them in.

So, let's say you've got someone who is in the hospital for end-of-life care for inoperable lung cancer. This person is pretty damn sick - "circling the drain" in medical speak. As such, the immune system is compromised. After 5 days in the hospital, a pneumococcus infection sets in to the lungs. He develops a fever at first and then starts goign downhill fast. He's got a DNR order, and in a couple of days hes got multiorgan system failure and dies.

Now, did this guy die of an iatrogenic illness? Or did this guy die from cancer? Or did this guy die from tobacco? Or did this guy die from multiorgan system failure? The truth is, he died from all of them. But upon what do you pin the cause?

My wife is hotter than your wife.

[riddler 0]

Quote

Again, I think it's like claiming that parachutes kill people by not slowing them down before impact. It's clearly the parachute's fault! Why the coverup?

I'm not sure that's a good analogy. This story doesn't involve, for instance, the drug companies acting a third-party suppliers, so it's hard to extend it to a parachute killing a skydiver. This is a story about a culture that deceives others about it's actions and also tries to convince itself that it did nothing wrong.

A better analogy might be a dropzone with a faulty plane (can you imagine??) that crashes and kills a load of skydivers. The dropzone then says that a bunch of crazy people who wanted to jump out of a plane got killed, so it's really their own fault for dying. The DZ doesn't want to take responsibility that maybe they had a hand in it. They were, after all, only trying to help the skydivers get what they wanted.

Trapped on the surface of a sphere. XKCD

[lawrocket 3]

Quote

tries to convince itself that it did nothing wrong.

Ah! Here's the point. This is where the discussion turns. This is indeed unfortunate news, but doctors are in a field of work where they can kill people, and it doesn't mean that they did anything wrong.

Earlier an example was cited about placing a stent. This stent is placed as a lifesaving measure. But, the stent can form a clot, throw off an embolus, and cause sudden death. In that instance, as a direct and proximate result of the doctor's actions, a patient died. So, did the doctor here "do anything wrong?" Probably not.

Iatrogenic illnesses are something that we don't have the technology to fully prevent. When you have a place filled with sick people, they tend to give each other what they have. For the really nasty ones, they have isolation units, i.e. keeping a person with TB isolated until 3 days of negative AFB screening.

The doctors, hospitals, etc., cannot protect someone against all illnesses. A person ends up with a staph infection of a wound. Okay, not too much can be done to fully prevent it. But if Joe Snuffy is recovering from a facial reconstruction and has an enterococcus infection in his face - well, now you are looking at something that was far more easily preventable.

My wife is hotter than your wife.

[riddler 0]

Quote

It was some "HealthGrades" or other publication that you got this from?

Well, I am sorry that I wasted your time with such drivel. Maybe I'm just biased toward this company because they are headquartered in the same state as me. But I smiled about your statement above because I remember thinking that very same thing about WebMD when they came out - "that's stupid - a website for medical advice". Earlier this year, I did a five-month contract with WebMD, which has become close to a $1 billion/year company. I guess the size and dollar value of a medical organization are the only things that really give it credibility. After all, the doctors that work for HealthGrades couldn't possibly be as competent as someone working for JAMA.

Or, maybe Healthgrades really has something? Hmm.

Quote

The HealthGrades study applied the mortality and economic impact models developed by Dr. Chunliu Zhan and Dr. Marlene R. Miller in a research study published in the Journal of the American Medical Association (JAMA) in October of 2003. The Zhan and Miller study supported the Institute of Medicine’s (IOM) 1999 report conclusion, which found that medical errors caused up to 98,000 deaths annually and should be considered a national epidemic.

Well, there is the basis of a JAMA model, which supports a report by the IOM. But, of course, the IOM isn't credible either, since it's not JAMA. In fact, JAMA disagrees with both HealthGrades and the IOM (I'm sure that competition doesn't factor into that at all), and disputes the report. Here is a link. I'll quote from it so that you don't have to waste your time reading it.

Quote

The AMA disputes the accuracy of the HealthGrades study, as well as the accuracy of the IOM estimate.
"Their methodology...relies on claims data that have inherent limitations, including not being able to explain complex situations or make cause-and-effect connections," says Donald J. Palmisano, MD, AMA's past president.
The HealthGrades study applied the mortality and economic impact models used in a research study published in the Journal of the American Medical Association (JAMA) in October of 2003.
However, it will not be published in a scientific journal, which would have forced HealthGrades' research to undergo independent criticism.
Samantha Collier, MD, Health Grades' vice president of medical affairs ...

Interesting that they didn't choose to publish their dispute, or really give any supporting evidence. What's more interesting to me is that despite the claim that "no one is disputing" (as I saw posted above) the fact that iatrogenic deaths happen, I can't seem to find the overall number for it from JAMA. They disputed this report, but don't want to furnish their own numbers? Why is that?

Trapped on the surface of a sphere. XKCD