James sat by his bedside, as any parent would, and wondered how this could happen.

Alex James knew how to exhaust himself. It started on his childhood swim team when his coach, a whistle-blowing, red-faced caricature, demanded he swim to the end of the Olympic-sized pool and back again—without taking a breath. And then, he’d make him do it again. And again. And again.

By Kevin Kunzmann & Jenna Payesko, MD Magazine.

Submerged between the pool walls, he learned to quiet his racing mind, harness the power of every cell in his thrashing arms and legs, and wring out every last ounce of energy that his racing heartbeat through his body. He was an athlete coming into his own, and quickly grew into a young man who could fly past his father in long-distance runs while sporting a smile.

In college, Alex channeled that drive towards the Air Force Reserve Officer Training Corps (ROTC) program at Baylor University. He was getting stronger by the day and became hell-bent on reaching the ranks of an Airman like it was the next pool wall. So when he collapsed in the middle of a run in the dry Texas heat one August day, his family was alarmed. For 5 days, his father, John T. James, Ph.D., sat by his bedside at a local hospital as his son endured test after test.

He received a cardiac MRI, a cardiac catheterization, an exercise stress test, and an electrophysiology test. Some of the tests caused Alex to develop a painful hematoma. One even left him bleeding from the groin. The attending cardiologist, an older man, cleared and released him after 5 days. His instructions in discharge papers were few—simply avoid driving for 24 hours.

With no one to tell him otherwise, Alex ran again on September 15, 2002. He collapsed again, but this time paramedics had to defibrillate him 3 times to restart his heart. He fell into a coma, and within 3 days, the driven, promising young athlete was dead.

James sat by his bedside, as any parent would, and wondered how this could happen. The then-chief toxicologist for the National Aeronautics & Space Administration (NASA) has a doctorate in pathology from the University of Maryland School of Medicine. He understood the procedures his son went through and set out to learn where they had gone wrong.

James told MD Magazine the details surrounding Alex’s death spurred physicians to suggest that his 2 surviving sons be tested for genetic conditions. Because of that, James worked his way into receiving Alex’s full medical records from his first collapsing incident. He pored over them, running notes by the responsible physicians and asking them about the reasoning behind their clinical decision making. He performed a cross-analysis — finding entries in Alex’s ROTC journal about persistent leg cramps from that summer, which implied he was suffering from dehydration.

James was sure that something just wasn’t adding up. Alex’s lead cardiologist never prescribed him a potassium replacement. In fact, his disregard for the low potassium levels meant the cardiac catheterization was unnecessary. A radiologist told James the cardiac MRI was conducted by technicians who were unsure of proper operating procedures for the machine’s new software. Moreover, the cardiologists had failed to diagnose Alex with an acquired heart rhythm condition, despite the fact that he had clearly scored well above the threshold for diagnosis. And atop these series of mistakes, James couldn’t find a single note suggesting that Alex should avoid exercise during his recovery.

“If he was effectively discharged and told not to run, I believe he’d be alive today,” James said.

The ‘if’s of medical errors are an insurmountable amalgamation of clinical anomalies: a physician doesn’t treat for potassium levels, a nurse administers therapy to the wrong patient, a technician doesn’t check for pre-existing conditions prior to a test. They are standout lapses in health care system efficiency, amplified by their repercussions and the efforts of those like James to bring them to light.

The conversation surrounding medical errors is typically limited to their extraordinary cost implications, both in terms of hospital budgets and human lives. There’s no doubt that understanding their burden is important, but efforts to prevent medical errors before they happen is a more ambitious and noble goal.

The Third-Most What?

One statistic has become famous among health care professionals in just 2 short years. A 2016 analysis of death rate data from an 8-year period by researchers at Johns Hopkins Medicine found 251,454 annual deaths in the US were the result of medical errors. By that count, it surpasses all but the nation’s 2 leading causes of death—heart disease and cancer—according to the Centers for Disease Control and Prevention (CDC).

It’s easy enough to say that medical errors are the third leading cause of death— several physicians have uttered the phrase in previous interviews with MD Magazine. And the fact remains that the Johns Hopkins study was pivotal because it answered a long sought after question about the frequency of medical error involvement in patient deaths. However, the CDC, which compiles an authoritative list of the most common causes of death in the US annually, is limited by its reliance on the International Classification of Disease (ICD) code. The ICD does not account for human and system factors in its mortality reports, and as a result, there is no federal metric for medical errors’ death toll.

Researchers worked to improve on the landmark former Institute of Medicine (IOM) report on errors in health care in 1999, in which the organization concluded that 44,000-98,000 annual deaths were caused by medical errors. In the years following the IOM report, multiple studies pushed that projected total up to 130,000-575,000 annual inpatient deaths caused by medical errors. The Johns Hopkins study had refined the results of 4 such studies to arrive at their estimates.

Still, clinicians have publicly argued that the numbers are what they are—estimates. Aaron E. Carroll, MD, a professor of pediatrics at Indiana University School of Medicine and a columnist for the New York Times, called the 2016 study results “more controversial than you think.” He noted that, of the 2.5 million annual deaths in the US, about 700,000 are hospitalized patients. If medical errors were accountable for 251,454 hospitalized patient deaths annually, then more than a third of all deaths at US hospitals are due to errors.

Carroll reasoned that even the best researchers are facing complex factors when trying to track which events cause death — and which are just correlated with death. “When someone dies in a car accident, it’s clear what caused the death,” Carroll wrote. “Same for a drug overdose, homicide or suicide. But when an 86-year-old with dementia and cancer dies and also had been given a drug in a slightly-too-high dose a few weeks earlier, is it the error that killed her or the underlying disease and age?”

In an interview with MD Magazine in May 2017, Tatsiana Singh, MPAS, PA-C, countered that the numbers that call medical errors the third leading cause of death are “gross underestimates,” because the majority of studies are based on medical chart review. “And that’s missing the fact that a lot of medical errors and mishaps do not get documented and never make it into the patients’ charts, and really are never detected,” Singh said.

Singh, a clinician at the Indiana State University Sycamore Center for Wellness, cited research showing that anywhere from 10% to 30% of autopsies find misdiagnoses. This alone does not include instances of incorrect surgical operations, delayed diagnoses, and miscommunication between different attending health care workers.

James, who published his own evidence-based estimate of hospital care’s association with patient harm in 2013, agreed the “third-leading cause of death” label is the incorrect way to measure the issue. He’s of the opinion that adverse events are common in hospitalized patients who are already very ill, and their deaths could be attributed to both their diseases and the incomplete care they received.

James’ study concluded that an estimated 210,000 preventable adverse events occur annually that at least contribute to the death of a hospitalized patient — a rate of approximately 1% of all deaths. A physician wrote to James shortly after reading the study, and asked if he really thought the rate could improve to better than just 1%.

“He’s got a point. It’s not going be easy to improve,” James said. “But it can be done.”

Airing Out Errors

In hindsight, James wished he followed the feeling in his gut. When his son was hospitalized, he was immediately skeptical of the facility. He was uncertain of the lead cardiologist’s capabilities too, and was later vindicated when he discovered the older physician had been grandfathered into an outdated standard of board certification that absolved him from having to earn continuing education credits.

The last email the cardiologist sent to James was a list of potassium-rich foods he believed his son would like. He remained respectfully skeptical, but now regrets holding onto his doubts. “I hate to tell people to be mistrusting of their doctor, but you have to be smart about your care,” James said. “You need to make sure your doctor treats you as part of a team.”

To ensure they’re doing their part to prevent medical errors, physicians must engage with individual patients, James said. He pointed to clues in Alex’s health history — his diet, his level of fitness — that would have indicated a diagnosis different from the one he was given. He believes physicians could benefit greatly from allocating more resources to learning a patient’s background. “Patients need to be better educated and treated equally, and doctors need to treat them as a partner in their care, and not try to just convince them on a therapy,” he said.

James has become a leading advocate for improved patient rights. He emphasized that a patient’s medical information should be more fully and immediately available, and that more focus needs to be placed on educating patients on their wellness and any means by which they’re treated. His organization Patient Safety America backs legislation supporting these changes, and his monthly newsletter to about 600 people — many of which are physicians — educates the public on recent clinical developments and how they could affect patients.

Much of his message is pro-communication and pro-transparency, both between physicians and patients, and between at-fault health care providers and their administration. He likened an ideal medical error reporting system to that practiced by the Federal Aviation Administration: aggressive in both finding the error and publishing it to ensure it doesn’t occur again.

Some find the issue to be that such transparency is taboo in US health care. Anthony Montgomery, PhD, associate professor of Work and Organizational Psychology at the University of Macedonia, told MD Magazine that learning in the medical field is akin to “treading in the deep end.” Medical students are immediately introduced to a culture that “doesn’t like mistakes, doesn’t like to admit there are mistakes, and doesn’t like errors.”

Kevin R. Campbell, MD, told MD Magazine at the time of the 2016 study that the very nature of “transition of care” enables the most common medical errors. Combined with the shortcomings of electronic medical record (EMR) programming, errors are the byproduct of an incomplete system. “System errors are the most common type of errors – these occur when the care systems and algorithms that are created within and between institutions are non-standardized and based on regional preferences,” Campbell said. “These inconsistencies can result in gaps in care. Safety measures and protocols are often inadequate to prevent error.”

To better alleviate EMR inconsistencies and remove outlying incentives in the payer-run system, James advocates for the implementation of a single-payer system. He said he empathizes with burdened physicians stretched thin with loads of administrative tasks, and hopes a simplified process could bring the medical error rate below 1%.

“Patients, physicians, and nurses need to get together and say we’ve had enough of how this is being done in this country,” James said. “We’ve got a lower life expectancy than others, and we’re spending too much money. It’s got to stop, but it’s going take clinicians coming together and getting legislators on the same page as them.”

APRIL 12, 2018