VA Medical mistakes: 700 dead in 2 years Report documents 2,927
errors at veterans hospitals around the nation

By Robert Pear
New York Times

WASHINGTON - Federal investigators have documented almost 3,000
medical mistakes and mishaps in less than two years at veterans
hospitals around the country, and more than 700 patients have died in
those cases, the Department of Veterans Affairs says in a new report.

The accidents and deaths occurred from June 1997 to December 1998, in
the first 19 months of a new policy that requires employees to report
medical errors and "adverse events." Since then, the department has
been getting such reports at a rate of more than 200 a month.

The problems include medication errors - like prescribing or
dispensing the wrong drugs - the failure of medical devices, abuse of
patients, errors in blood transfusions, surgery on the wrong body
part or the wrong patient, improper insertion of catheters or feeding
tubes, and a variety of "therapeutic misadventures" that caused
serious injuries or deaths.

The comprehensive self-examination by the VA believed to be the first
of its kind by any health care system in the nation, shows what could
be expected if all hospitals had to report their errors as
recommended recently by the National Academy of Sciences. The number
of reported errors would be high, but health care executives would
get useful information about problems that need to be fixed,
officials said.

3,000 errors logged at VA hospitals

Starting in June 1997, the VA ordered its hospitals to report their
mistakes to the agency's regional offices, which in turn send the
information to Washington, where it is logged into an official file
known as the patient safety register. Hospitals must try to identify
the causes of each incident to reduce the likelihood of repetition.

The new emphasis on patient safety was prompted by several factors:
sporadic complaints of substandard care at veterans hospitals,
pressure from Congress and the zeal of a senior official, Dr. Kenneth
W. Kizer, who was under secretary of veterans affairs from October
1994 to June of this year.

For decades, the veterans health care system had a reputation as
hidebound and bureaucratic. But under Kizer, it emerged as a national
leader in efforts to improve patient safety.

Spells out 'adverse events'

The report's author, Dr. James E. McManus, a surgeon from New York
City who is the VA's medical Inspector, said: "The adverse events
reported by the VA were so serious that 24 percent of the patients
died. One in four died." The study found 2,927 errors in the first 19
months of mandatory reporting, and 710 deaths.

The number of deaths in 1999 has not been determined. While each
hospital analyzes its own cases, the department has not yet analyzed
this year's figures for the nation as a whole.

As medical inspector, McManus is a sort of watchdog and ombudsman,
continually evaluating the quality of care provided to veterans. The
department runs the nation's largest health care delivery system,
with 172 hospitals, 132 nursing homes and more than 650 outpatient
clinics.

McManus and other health care experts said they believed that the
prevalence of errors at veterans hospitals was similar to that at
other hospitals. "I don't think it's any different from the private
sector." McManus said.

Dr. Donald M. Berwick, a member of the study panel convened by the
National Academy of Sciences, said "The first sign of a serious
endeavor to deal with errors is that the number of reported errors
should go way up."

The Joint Commission on Accreditation of Healthcare Organizations,
which inspects 80 percent of hospitals in the United States,
encourages private hospitals to report "unexpected occurrences"
involving death or serious injury to patients, but it does not
require such reports.

Since January 1995, the commission says, 714 such events have been
voluntarily reported. The Department of Veterans Affairs had tallied
a much larger number of mishaps in just 19 months of reporting.

Medical errors prove deadly

The institute of Medicine, an arm of the National Academy of
Sciences, said last month that medical errors killed 44,000 to 98,000
people a year in hospitals alone. More people die from medical
mistakes each year than from highway accidents, breast cancer or
AIDS, it said. The institute said Congress should require hospitals
to file reports with state governments, disclosing any medical errors
that cause death or serious harm.

Of the 2,927 "adverse events" analyzed by the VA, 171 were medication
errors, in which patients received the wrong medication. Patients
died in 22 of these cases. McManus said he believed such drug errors
were "greatly underreported."

The veterans agency defines "adverse events" as untoward incidents,
illnesses or injuries caused by medical treatments or directly
associated with care provided by the department.

Of the other adverse events described in the VA report, about 540
patients were injured in falls at veterans hospitals and nursing
homes. In addition, the department said 277 patients committed
suicide at veterans hospitals or soon after being discharged, and 476
patients tried to kill themselves but survived.

Doctors said some of the suicides might have been prevented if the
patients had received appropriate treatment for depression.

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Claudio Acuña
claudioacuna@...