Land O' Mistakes As you surely know, I've written numerous times before about iatrogenic (doctor-related) causes of death. To recap, doctors and mainstream medical treatments cause more deaths in the United States than all other causes except cancer and heart disease… Shocking, but true. According to a 1999 Institute of Medicine report, as many as 98,000 Americans die of surgical errors, drug interactions, hospital-borne infections, misdiagnoses, or just plain unspecified medical negligence every year. And since the publication of that report, 22 states have adopted laws requiring hospitals to reports the most serious of these mistakes, according to a recent Associated Press article. What defines the "most serious" of mistakes? According to the National Quality Forum, a group dedicated to raising hospital standards, it's things like amputating the wrong limb, sending a child home with the wrong family - that kind of stuff. These "never" errors (they've identified 27 of them) are so named by the group because they're so grossly negligent that they're never supposed to happen. Ever. Flash forward to 2005. Now, some of the first results of this mandatory reporting are starting to become public. According to the data, in just one of these complying states - the sparsely populated Minnesota - 20 people died in 99 reported examples of gross negligence in that state's hospitals in the 15 month period between July of 2003 and October of 2004. And if the AP has it right, every one of them died from these "never" mistakes. Keep in mind that this statistic isn't a complete listing of the God-knows-how-many North Star state residents during this same time period who were maimed, infected, crippled or rendered mentally impaired because of medical errors - only those that died or were damaged as an UNDENIABLE RESULT OF THEM. Considering this, who knows how many Minnesotans were really affected by iatrogenic causes? I'm sure that only the most egregious examples ever made it to the "reporting" stage. And among these were: Medication errors, equipment malfunctions, fatal burns and falls - and at least 31 instances of surgeons leaving foreign objects in patients! And if you think the medical care is any better in more "civilized" states, think again… **************************************************** Duke pulls a D'oh! How's this for confidence inspiring: One of the country's most widely known and respected hospital systems accidentally washed thousands of surgical instruments not in the customary antibacterial detergent… But in used elevator hydraulic fluid! According to the Herald-Sun newspaper, a pair of Duke University-affiliated hospitals mistook the hydraulic fluid - which had been drained into empty detergent canisters by elevator service technicians - for the washing agent, and routinely loaded it into their instrument-cleansing machines for the better part of TWO MONTHS before the mix-up was discovered. Hospital higher-ups are insisting that the risk of any harm from any such residual fluid contamination during surgical procedures is remote. Yeah, right. That's why there's a warning on bottles of other types of hydraulic fluids (like automotive brake fluid) that says "harmful or fatal if swallowed." They put that label on there because it's harmless to ingest! The hospitals have sent letters to the estimated 3,900 patients who were exposed to the fluid, but don't expect any complications from the snafu. Not that we'd ever hear about it anyway… "Hydraulic fluid contamination" probably isn't on the "never" list of reportable errors.
Never saying never when it comes to the establishment,
William Campbell Douglass II, MD | 
