Medical Mistakes Study Old News at Harvard

A report by the Institute of Medicine (IOM), released earlier this month, attracted national attention with the finding that 44,000 to 98,000 Americans are killed every year by medical mistakes.

But, among Harvard health care officials and staff at Harvard-affiliated hospitals, this news was hardly a shock.

Associate Professor in the Department of Health Policy and Management Donald M. Berwick was one of the 19 authors of the IOM study, which called for Congress to create a "national patient safety center" to deal with the problem.

And Berwick is not the first Harvard faculty member to study medical mistakes. Harvard School of Public Health (HSPH) researchers in 1995 found dangerous prescription errors at a Boston-area hospital, and helped design a computer system to alleviate the problem.

Finally, though University Health Services (UHS) says its patients do not usually require the kind of treatments in which errors are most common nationwide, officials say they've taken steps to ensure that medical mistakes are not a problem.

Survey Gains National Attention

Berwick is part of an IOM committee that periodically submits reports and recommendations on various health issues to Congress.

Researchers have long been aware of the magnitude of the problem presented by medical errors, he said, but the IOM study hurtled the issue into the public eye.

"There was an immediate public reaction," Berwick said. "It was covered on network TV, and on the front page of all major newspapers."

Since the report was released two weeks ago, Berwick has appeared on the Today Show and on several other news programs, just as other committee members have.

One local case in particular spread interest in identifying problems with medical errors and helped spark studies like this one, he said.

In 1995, Betsy Lehman, a Boston Globe reporter, underwent chemotherapy for breast cancer at the Dana Farber Cancer Institute.

During one treatment session, Lehman was given too much of the chemicals being used to treat her tumor, and died as a result.

Her death was covered in the Globe and other local media, but Berwick says the kind of error that killed Lehman case isn't unusual.

But the question of blame sometimes makes people reluctant to report or take responsibility for such errors. Berwick says that most errors, in fact, are not directly caused by human mistakes but by breakdowns in administrative or communications systems.

"The most important thing is to understand that most errors are not caused by bad people," Berwick said.

Studying the Issue

In 1995, researchers from HSPH and Harvard Medical School (HMS) studied misuse of medicine--dangerously wrong prescriptions and treatment--at Brigham and Women's Hospital in Boston.

The team, including HSPH professor Lucian Leape and David W. Bates of HMS, found that 6.5 percent of all patients were the victims of some kind of medication error.

After the study, Brigham and Women's Hospital instituted computer programs to regulate drug misuse, and found that the rate of error decreased by 55 percent.

Since then, Mass. General Hospital has begun to implement a similar system, and as a result of this month's report, Leape said, other hospitals both in the Boston area and nationwide are heading in the same direction.

Another Harvard study involving medical errors was the Harvard Medical Practice Study of 1990, which Leape worked on.

This study looked at medical records from 30,000 New York hospital patients, looking for medical errors.

"A lot of the best work in the field is done by professors affiliated with Harvard," said Bates, who is associate professor of medicine and chief of the Division of General Medicine at Brigham and Women's.

An Ounce of Prevention

According to UHS Director David S. Rosenthal '59, most medical errors are not caused by human error, but rather by breakdowns in communication.

Especially hard to keep track of are patients' medications. This ignorance is dangerous because the wrong mixture of drugs can lead to violent reactions in patients.

"There are certain things we know we can use to prevent this misuse," Rosenthal said. One of these preventive measures is a computer database containing patients' medication information.

UHS also aims to reduce the potential for errors by permanently assigning patients to one team of physicians.

However, Rosenthal said, students and other members of the Harvard community should still take extra precautions.

"When you pick up medicine at the pharmacy, ask questions," Rosenthal recommended, urging a good understanding of the effects of the medication.