A study by Sklar, D.P., et al., addressing unanticipated deaths occurring within seven days after emergency department discharge made several observations. There were 30 deaths per 100,000 discharges, half of which were unexpected but related to the ED visit and 60% of which involved a possible error. There were four recurring themes:
The Institute of Medicine’s (IOM) legendary report in 1999, “To Err is Human,” estimated 98,000 iatrogenic deaths making it the sixth leading cause of death in the U.S. A later study in 2010 yielded almost twice that many deaths, at 180,000. The most recent study in 2013 suggested the numbers range from 210,000 to 440,000 deaths per year. The latter number would make it the third leading cause of death after heart disease and cancer. However, these numbers can only be estimated because medical records are often inaccurate and providers might be reluctant to disclose mistakes.
Niki Carver ; Vikas Gupta ; John E. Hipskind .
One of the 1999 IOM report’s main conclusions is that the majority of medical errors do not result from individual recklessness or the actions of a particular group. More commonly, errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them. For example, stocking patient-care units in hospitals with certain full-strength drugs, even though they are toxic unless diluted, has resulted in deadly mistakes. Thus, mistakes can best be prevented by designing the health system at all levels to make it safer–to make it harder for people to do something wrong and easier for them to do it right. Of course, individuals should be still held accountable when an error can be attributed to them. As an example, anchoring bias (persistence with an initial diagnostic impression despite evidence of another diagnosis) is a major source of diagnostic error. When an error occurs, however, blaming an individual does little to make the system safer and prevent someone else from committing the same error.
A medical error is a preventable adverse effect of medical care, whether or not it is evident or harmful to the patient. Among the problems that commonly occur during providing health care are adverse drug events and improper transfusions, misdiagnosis, under and overtreatment, surgical injuries and wrong-site surgery, suicides, restraint-related injuries or death, falls, burns, pressure ulcers, and mistaken patient identities. High error rates with serious consequences are most likely to occur in intensive care units, operating rooms, and emergency departments. Medical errors are also associated with extremes of age, new procedures, urgency, and the severity of the medical condition being treated. This activity outlines common sources of medical errors and highlights the role of the interprofessional team in improving the care of the patient and enhancing safety by using techniques to avoid errors.
A medical error is a preventable adverse effect of medical care, whether or not it is evident or harmful to the patient. Among the problems that commonly occur during providing health care are adverse drug events and improper transfusions, misdiagnosis, under and over treatment, surgical injuries and wrong-site surgery, suicides, restraint-related injuries or death, falls, burns, pressure ulcers, and mistaken patient identities. High error rates with serious consequences are most likely to occur in intensive care units, operating rooms, and emergency departments. Medical errors are also associated with extremes of age, new procedures, urgency, and the severity of the medical condition being treated.
The most common medical errors in the United States by occurrence are: adverse drug events, catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), injury from falls and immobility, obstetrical adverse events, pressure ulcers, surgical site infections (SSI), venous thrombosis (blood clots), ventilator-associated pneumonia (VAP), wrong site/wrong procedure surgery (most common basis for quality of care violations), and the following five most mis-diagnosed conditions: cancer related issues; neurological related issues; cardiac-related issues; timely responding to complications during surgery and post-operatively; and urological related issues. 
Figure 2 explanatory note: Estimates from the literature of the proportion of patients that received various low-value services, out of the relevant patient population. The populations are based in four locations (US: circle/green, Canada: triangle/orange, Australia: diamond/purple, Sweden: upside-down triangle/pink). Abbreviations: Patients (pts); with (w); cancer (cn); imaging (img); preoperative (preop); total knee arthroplasty (TKA); lower back pain (LBP); computed tomography (CT); benign prostate hyperplasia (BPH); primary androgen deprivation therapy (pADT); bone scintigraphy (BS); positron emission tomography (PET); tumour marking studies (TMS); dual-energy x-ray absorptiometry (DXA); echocardiography (ECG); pulmonary function test (PFT); ipsilateral adrenalectomy (IA); radioactive iodine treatment (RAI); carotid artery disease (CAD); congestive heart failure (CHF); magnetic resonance imaging (MRI). Figure adapted and updated from Chalmers and Elshaug. 4
While there are few direct measurements of the proportion of health care spending attributable to overuse, evidence is emerging to suggest the cost may be considerable. A study of inappropriate use of bone scans for US Medicare beneficiaries with prostate cancer found that 21% and 48% of patients at low and moderate risk of bony metastases underwent at least one scan, despite recommendations against scanning in these groups, at a cost of $11,300,000 annually. 181 High rates of overuse are estimated by experts to contribute substantially to health care spending in the US (and to its mediocre quality); 182 based on a conservative estimate, the US spent at least $270 billion on overuse in 2013 2 (even as millions of Americans lack adequate access to basic health care). Overuse may also strains health care budgets in other countries. 183 In Australia, where many common services are believed to be overused, 5 the growth in health care expenditure from the rising volume of medical services has been identified as the greatest threat to the financial position of the government, and a bigger cause of health cost increases than population growth or ageing. 184
What is overuse?
Overuse occurs across a wide range of medical specialties.
We use the term “overuse” to refer to any services that are unnecessary in any way and for any reason. The related terms, “overtreatment” and “overtesting,” indicate the inappropriate delivery of particular types of services.
Surgery and other invasive procedures are likely to be commonly overused in high-income countries. Though rates of directly-measured overuse were not reported, Elshaug and colleagues identified more than 150 “low-value” services in use in Australia, 5 and in the US, up to 42% of Medicare beneficiaries were found to have received at least one of 26 low-value treatments, with these low-value interventions accounting for 2.7% of overall Medicare spending. 32 Such findings are suggestive of widespread overuse of these services.
Comité de rédaction
Dr B. Kiefer, rédacteur en chef ; Dr G. de Torrenté de la Jara, Pr A. Pécoud, Dr P.-A. Plan, rédacteurs en chef adjoints ; M. Casselyn, M. Balavoine, rédacteurs.
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