Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Wow! - Stunning figures
- Ron Law (3 March 2001)
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The value of data about adverse events
- Ricardo Pardo (3 March 2001)
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Adverse events in British hospitals
- K Sankar (4 March 2001)
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Were adverse drug reactions included?
- John Wilson (7 March 2001)
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Right in retrospect?
- R E Ferner, J K Aronson (8 March 2001)
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Will the response to adverse events highlight double Standards?
- Janet Richardson (8 March 2001)
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"The eye of the beholder" - a threshold effect
- B T Collopy, I G McDonald (9 March 2001)
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Explaining the Evidence on Adverse Events
- Stephen Heasell (9 March 2001)
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Sometimes "adverse events" may be inevitable
- David Griffith, Paul Diggory, Anand Mehta (9 March 2001)
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In-hospital adverse events: Preventive strategies, not epidemiological studies, are needed
- Tuan V Nguyen (12 March 2001)
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Radiological errors reporting does not identify errors leading to complaints and litigation.
- Sam Chakraverty, John Wright (15 March 2001)
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Adverse events in British hospitals
- Rosalind Plowman, Jenny Roberts, Nick Graves, Barry Cookson, Lynda Taylor, Mark Griffin (26 March 2001)
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Tip of the Iceberg, Need expanded definition of adverse events.
- Stephen Bezruchka (2 April 2001)
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Quick Risk Comparison
- Barry Whittingham (8 April 2001)
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Re: Quick Risk Comparison
- Joseph Watine (10 April 2001)
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Ron Law
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Based on 37,000 patients at these two hospitals we're looking at about 10% suffering adverse effects and 8% of them dying. Using UK 'value of life' figures that works out to about 222 million pounds of lost life-economic worth (DOT uses a figure of 0.75 million pounds)per year. That's TWO hospitals only. Gosh - the UK thinks the current foor in mouth problem is affecting the economy - at least that's a 1/20 year event! Any other industry and there'd be political chaos - why the double standards. When is enough, enough? NZ figures soon to be published will reaffirm the medical killing fields. Ron Law is an enthusiastic supporter of evidence based medicine and member of the New Zealand Ministry of Health working group advising on strategies for reporting medical error. |
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Ricardo Pardo, General Surgeon Ciudad Real. Spain
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I would like to congratulate Professor Vincent et al. for the quality of his work and the value in publishing it. It is the main work published in Europe related to incidence of adverse events and will be used by countries like mine to encourage research in this field. Adverse events in hospitals happen everyday but we clinicians do not have any data related to what is happening, why is happening and what can be done to decrease them. This study demostrates that it can be done in Europe and all the National Health Services in our different countries should be prepared to perform such studies in order to know which is the real situation in our hospitals and try to find solutions to improve it Dr. Ricardo Pardo
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K Sankar, Consultant in Genitourinary Medicince Newcastle General Hospital
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This study provides very useful data on adverse events. Unfortunately the popular press has already given a misinterpretation of the figures provided by the study. While the authors clearly state that only 48% of the adverse events recognised by the study team were preventable a newspaper report claims the following: "Extrapolating the findings to the 8.5 million patients admitted to NHS hospitals in England each year implies errors contribute to the deaths of 68,000 patients and permanent or moderate injury to more than 200,000. In total, 850,000 patients are victims of errors,half of which are preventable" (The Independent, 02/03/2001). The paper does not provide information on the preventablity of the 34% of the events that resulted in moderate and severe permanent impairment or death. This information would have been very useful in assessing the seriousness of the preventable adverse events. Another aspect of the clinical management that was not in the remit of this study is an assessment of the possible adverse outcomes of the diseases without the interventions. While the data on the adverse events provide a salutary lesson and an agenda for clinical governance, information on the prevention of probable adverse outcomes by the clinical interventions would give a balanced perspective and allay public anxieties about the quality of care. Dr K N Sankar
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John Wilson, Retired paediatric neurologist Great ormond Street
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Dear Editor, It is unclear in Professor Vincent's important article if the events identified included adverse drug reactions. If they did, it will be helpful to show the percentage of adverse drug reactions in each professional group. If they didn't, this is obviously another dimension to the problem. John Wilson |
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R E Ferner , J K Aronson
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The study by Charles Vincent and colleagues (3 March 2001, page 517) shows that adverse events are probably frequent in British hospitals, but the authors fail to make a persuasive case for extending their study. At best, a larger study of the same design could only give an imperfect estimate of the true incidence of adverse events, because case notes are an incomplete record of events, and are difficult to interpret in retrospect, and because valuable collateral data from hospital staff and others are lost.[1] The worth of a single clinician's analysis of the impact and preventability of adverse events was not assessed, but, by analogy with adverse drug reactions, it is likely to be fallible.[1,2] For instance, the authors quote an example of a man who developed osteomyelitis as a consequence of 'failure to manage the leg ulcers aggressively.' We are given no further details, so we do not know whether they are suggesting that different antibiotic drugs, higher doses, or a longer duration of treatment might have been beneficial. We cannot judge how likely it is that 'aggressive' treatment would have succeeded. Infected leg ulcers are difficult to treat and osteomyelitis may have occurred anyway. Nor do the authors say whether the subsequent amputation was a consequence of osteomyelitis or of another factor such as vascular disease. It is not clear that it was reasonable to have labelled this event an adverse event. Retrospective case record analysis may have 'provided the foundation and driving force for initiatives' in the United States, as Vincent et al. say, but it has been superseded by prospective study,[1] systems analysis,[3] and the assessment of interventions.[4,5] R E FERNER
JK ARONSON
[1] Bates DW, Cullen DJ, Laird N, Petersen LA, Small SD, Servi D, et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA 1995; 274: 29-34. [2] Karch FE, Smith CL, Kerzner B, Mazzullo JM, Weintraub M, Lassagna L. Adverse drug reactions - a matter of opinion. Clin PharmTherap 1976; 19: 489-92. [3] Ferner RE, Aronson JK. Medication errors, worse than a crime. Lancet 2000; 355: 947-48. [4] Bates DW, Leape LL, Cullen DJ, Laird N, Petersen LA, Teich JM, Burdick E, Hickey M, Kleefield S, Shea B, van der Vliet, M, Seger DL. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA 1998; 280:1311-1316 [5] Nightingale PG, Adu D, Richards NT, Peters M. Implementation of rules based computerised bedside prescribing and administration: intervention study. BMJ 2000; 320: 750-3. |
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Janet Richardson, Chairman of the Research Council for Complementary Medicine. Oxford Brookes University
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Professor Vincent and his team have produced some excellent, albeit worrying work in this study. Many of us who work in the NHS may feel this is the tip of the iceberg - particularly if adverse drug events (as highlighted in another response) were not included. It will be interesting to see how Government and Professional bodies will respond. Clearly prompt action can be taken in some cases - I read this morning in the 'Metro' that the Medicines Control Agency has imposed a ban on Traditional Chinese Medicines that contain a substance that was 'blamed for causing kidney failure in two women'. Perhaps this is an indication of double standards? That remains to be seen. |
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B T Collopy, CQM Consultants and Centre for the Study of Clinical Practice Melbourne, Australia, I G McDonald
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Dear Sir, At first sight the results are alarming.The rate of AEs for Australia- 16.6%,for the UK-10.8% and for the US-3.7%. We concede the importance of measuring the extent of AEs and taking action to reduce their number. However the measures used should be reliable and reproducible.It should be noted that the mortality rates are in the reverse order, with the US-13.6%, the UK-8% and Australia-4.9%. When charted the figures provide an almost staight line. The methodological problem most likely relates to the threshold determination, with a high threshold for AEs providing small numbers of serious events and a low threshold large numbers of minor events.This study weakness is now recognised, but the community, particularly in Australia and the UK need to be reassured that the health care standards in their two countries are unlikely to be inferior(to the US) to the extent suggested by these "comparative" studies.A large difference was in the "eye" (or attitude)of the reviewers. |
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Stephen Heasell, Head of Economics Division Nottingham Trent University
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The products of the database envisaged by the NHS adverse event pilot study research team (BMJ 2001,322:517-519) would be very welcome. It would be useful to couple the database with a convincing explanation for the extent of adverse events and for why more resources have not been spent in attempts to reduce either their extent or their adverse consequences, despite the evident public concern. Indeed, why has there apparently not yet been a systematic database that encompasses adverse events across the NHS? It might be that more of the scarce resources available to the NHS would be directed to these purposes, by those in a position to do so, if they could capture more of the benefits or savings from doing so or if they themselves were to experience more adverse consequences associated with the events in question. If so, attention to the relevant incentive structures might prove to be part of a cost effective and appropriate response to the issue. In any case, the application of some additional insight into what limits the commitment of scarce resources in such a way would complement the prospective evidence base. Together, they might help in the development of a workable strategy for improving the consistent quality of service in the NHS for patients which their advocates seem to want. A greater confidence in our ability to select a cost effective and appropriate response, based on sound explanation as well as sound information, might even increase the preparedness to bear the cost of a better database more quickly. |
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David Griffith, Consultant Physicians, Care of Older People Mayday Healthcare NHS Trust, Paul Diggory, Anand Mehta
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Editor, The article by Vincent and colleagues is both salutary and helpful in that it again draws attention to possible ways of improving practice.1 We are concerned however that no mention has been made of what might be called “no win” situations where there is a high chance of an adverse event whichever course of action is pursued. As far as we can ascertain from the “criteria for adverse events” no allowance is made for this and indeed it is probably impossible to do so. However, it is important to acknowledge such a problem when commenting on the findings. Even in the example quoted there is an element of this dilemma. Osteomyelitis as a complication of leg ulceration is probably quite rare, whereas the alternative, apparently preferred option of more aggressive management with antibiotics could have resulted in significant antibiotic- induced complications. Older people by virtue of the common problem of multiple pathologies are particularly candidates for “adverse events”. Should you increase treatment for cardiac failure in someone with a degree of renal impairment and risk precipitating frank renal failure (adverse event of commission), or risk them dying from undertreated cardiac failure (adverse event of omission)? Comparisons with civil aviation procedures seem popular in relation to adverse events and risk reduction. Perhaps we could suggest “We are flying a rather old and unreliable aircraft. Would you rather crash here or there?” David Griffith, Paul Diggory and Anand Mehta
1) Vincent C, Neale G and Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. BMJ 2001; 322: 517-9 (3 March) No competing interests |
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Tuan V Nguyen, Senior Fellow University of New South Wales
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In a recent survey, Vincent et al. [1] have estimated that approximately 11% of hospital admissions in two British hospitals were associated with an adverse event. The authors argue for a larger scale study to document the prevalence of medical adverse events in the UK. However, their estimate of in-hospital adverse events is well within the statistical boundary of previous estimates obtained by much larger US [2] and Australian [3] studies. Therefore, their argument for yet another large study seems weak and perhaps irrational, particularly in light of a recent UK study which has documented the problem of substandard care [4]. We believe that there is sufficient and necessary evidence to state that medical error is common; and that there is a urgent need to develop strategies to prevent or reduce the error, not to spend resources for conducting another descriptive epidemiological study. Among the adverse events, death, cardiac arrest and unplanned admissions to intensive care unit (ICU) are probably the most serious occurrences. Most of those events have their genesis in the general wards. The events are not sudden nor unpredictable, because they are usually preceded by signs of clinical instability. Recognising these facts, a system called the Medical Emergency Team (MET) has been developed and trialed since 1990 [5]. The system has three components: identifying high-risk patients at an early stage; providing a rapid appropriate response to the patients; and providing feed-back data on the effectiveness of the MET system. Under the MET system, when a patient's clinical condition is unstable (as judged by specific criteria), a call is immediately placed to the MET for intervention. We postulate that the MET system is an effective strategy to reduce in-hospital adverse events. In a prospective study conducted in a 300-bed tertiary referral teaching hospital in Melbourne, after implementing the MET system, the incidence rate of cardiac arrest was reduced by 50% (unpublished data). Moreover, in a recent six-month prospective study, the incidence rates of cardiac arrest, deaths, and unplanned ICU admissions in one MET-based hospital was lower than those in the two hospitals without the MET system; however, after adjusting for case-mix factors, a statistically significant difference was only observed in the rate of unplanned ICU admissions [6]. Nevertheless, further randomised controlled studies with multiple hospitals are required to systematically evaluate the effectiveness of the MET system. Such a study is underway in Australia and New Zealand, and we suggest that a similar strategy and study be considered by the National Health Service. Tuan V. Nguyen1,2, Michael D. Buist3, Ken M. Hillman1,2
Correpondence author:
Dr. Tuan V. Nguyen,
The Simpson Centre for Health Service Innovation,
Liverpool Hospital,
Elizabeth Street, NSW 2170
Australia.
References 1. Vincent C, Neale G, Woloshynowych. Adverse events in British hospitals: preliminary retrospective record review. BMJ 2001; 322:517-9. 2. Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, Newhouse JP, Weiler PC, Hiatt HH. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 1991; 324:370-6. 3. Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD. The Quality in Australian Health Care Study. Med J Aust 1995;163:458-71. 4. McQuillan P, Pilkington S, Allan A, Taylor B, Short A, Morgan G, Nielsen M, Barrett D, Smith G, Collins CH. Confidential inquiry into quality of care before admission to intensive care. BMJ 1998; 316:1853-8. 5. Hourihan F, Bishop G, Hillman KM, Daffurn K, Lee A. The medical emergency team: a new strategy to identify and intervene in high risk patients. Clin Intensive Care 1995;6:269-72. 6. Bristow PJ, Hillman KM, Chey T et al. Rates of in-hospital arrests, deaths and intensive care admissions: the effect of a medical emergency team. Med J Aust 2000;173:236-240. |
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Sam Chakraverty, Consultant Radiologist, Associate Medical Director Ninewells Hospital and Medical School, Dundee, Bradford Hospitals NHS Trust, Bradford, John Wright
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Sir, Vincent reports that 10.8% of patients experienced an adverse event in hospital (1). There has been increasing recognition about the importance of medical errors and what can be learnt from them (2). Rather than undertaking yet further research to describe the scale of the problem, efforts would be better invested in designing and evaluating effective interventions to reduce it. Errors in diagnostic radiology have been recognised and analysed for many years (3,4). The Royal College of Radiologists has recommended errors meetings for radiologists to discuss mistakes and learn from them. We reviewed the results of two years of self-reporting of radiological errors in Bradford to determine how many resulted in litigation or adverse clinical outcomes. Approximately 200,000 examinations were reported annually by 9 radiologists. During 1998 and 1999 all reported errors that were identified from repeat examinations or by clinicians were reviewed by one of the authors (SC). Minor errors were discarded. The remainder were reviewed anonymously in errors meetings and the lessons discussed. Complaints and litigation cases in the department were also reviewed for the years 1998 to 2000. 35 major errors were reviewed by all radiologists. The majority were reported by the individual who made the error. None resulted in complaint or litigation. In addition none of the complaints or legal cases during this period could be traced back to reported errors. One of the major justifications for risk reporting and management strategies is to reduce complaints and malpractice claims. However we found no evidence that a self-reporting system achieved this. The number of identified errors reported was small in comparison to the number of examinations carried out. Experience of errors meetings from other hospitals suggests that this number is typical. It is inevitable that there were many other errors that were not identified or not reported. The errors meetings did lead to the implementation of two changes in practice, which were minor issues of protocol. They also provided a forum for education and debate. However it is unclear whether they resulted in better practice or reduced subsequent errors. Claims to the contrary should be evidence-based. In the current NHS climate, it may be that the wrong errors continue to be reported. S. Chakraverty
Dr. J. Wright
1. Vincent C, Neale G, Woloshynowych M. Adverse events in British Hospitals: preliminary retrospective record review. British Medical Journal (2001) 322:517-9. 2. Department of Health. Organisation with a memory. Report of an expert group on learning from adverse events by the Chief Medical Officer. London:HMSO 2000. 3. Smith MJ. Error and Variation in Diagnostic Radiology. Pub. Charles C Thomas, Springfield, Illinois, USA , 1967. Library of Congress Catalog Card No. 67-116118. 4. Robinson PJ. Radiology’s Achilles’ heel – error and variation in the interpretation of the Rontgen image. British Journal of Radiology (1997) 70:1085-98. No competing interests. |
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Rosalind Plowman , Jenny Roberts, Nick Graves, Barry Cookson, Lynda Taylor, Mark Griffin
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Dear Sir, Re: Adverse events in British hospitals: preliminary retrospective record review. BMJ, 322; 517-519 The authors of a recent paper commented that 'the epidemiology of adverse events has not been studied in Britain.'1 Neither the paper or the additional information on the BMJ Website provides detailed information on what constitutes an adverse event. However, it would appear from the example given, that hospital-acquired infections (HAIs) are included in this category. Assuming this to be the case, it would have been interesting to know whether all HAIs were classified as adverse events caused by medical management, or whether some infections were excluded because they were viewed as unfortunate consequences of the disease process. If all HAIs were included in this category then there is information on both the epidemiology of this particular adverse event,2 and the economic burden imposed.3 The paper reports that 46% of the adverse events identified were judged preventable, and that preventable events cost the NHS around £1bn per year in terms of additional bed days.1 It would be interesting to know what proportion of these preventable events were HAIs and how this judgement was made. Recent subjective estimates suggest that 15% of HAIs could be prevented through improvements in infection control,4 earlier but more objective data suggests that it might be twice this figure.5 If 15% were prevented then, based on the results of recent estimates of the economic burden of HAIs, the prevention of this type of adverse event alone would result in the release of at least 546,000 bed days and resources valued at £150 million. These estimates are limited to HAIs occurring in adult non-day case patients admitted to selected specialties of NHS Hospitals in England (approximately 70% of adult non-day case admissions).3 The overall number of bed days and resources released from the prevention of this type of adverse event is therefore likely to be considerably higher. 1. Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. BMJ 2001;322:517-519. 2. Emmerson AM, Entstone J, Griffin M, Kelsey MC, Smyth ETM. The second national prevalence survey of infection in hospitals - Overview of the results. J. Hosp Infect 1996(32):175-190. 3. Plowman R, Graves N, Griffin M, Roberts JA, Swan AV, Cookson B, et al. The rate and cost of hospital acquired infections occurring in patients admitted to selected specialties of a district general hospital in England and the national burden imposed. J Hosp Infect 2001;47(3):198- 209. 4. Report of the Comptroller and Auditor General. The Management and Control of Hospital Acquired Infection in Acute NHS Trusts in England. London: The Stationary Office Limited, 2000. 5. Haley RW. Managing hospital infection control for cost-effectiveness: a strategy for reducing infectious complications. Chicargo: American Hospital Publishing, 1986. Rosalind Plowman
Jennifer A Roberts,
Nicholas Graves,
Mark A S Griffin
Barry Cookson,
Lynda Taylor
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Stephen Bezruchka, Department of Health Services, School of Public Health and Community Medicine University of Washington, Seattle, USA
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The studies on adverse events associated with medical care only deal with those invovling a hospital record. We have no data on events that don't interface with a hospital admission. A substantial portion of these may result in death, and not be associated with a hospital admission. The hosptial deaths may only be the tip of the iceberg. In the United States, and in most poor countries around the globe, we need to expand the definition of an adverse event. This can include the financial effect on a family of having to pay a medical bill. In my experience working in Nepal, where private practice tends to be very cost- intensive, and results in the ordering of many expensive tests of dubious need. The patient and her/his family have no way of deciding whether the expense is justified. Families will borrow money to pay for the care and then limit spending on basic needs such as food, with resulting harm. The same happens to families in the United States who incur huge medical costs. The United States spends 42% of the world's health budget (WHO 2000), and ranks behind all other rich countries in what I call the Health Olympics (ranking of countries by life expectancy). We should seriously question what we buy with health care. |
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Barry Whittingham, Risk Consultant Home
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If, say, 10% of all admissions to medical facilities lead to an adverse event,and say, 10% of these result in a fatality, then the chance of death due to such an event is one in a hundred per person-admission (or treatment). That is, a probability of 0.01 on average (often expressed mathematically as 1E-02). If a train commuter was exposed to the same risk as this due to adverse events on the railways, then the result would be a fatality rate of one per hundred passenger-journeys. Thus if the commuter made, say, twenty journeys per month, his life expectancy would be about five months (slightly longer than a Battle of Britain fighter pilot). This would quickly put paid to rail travel. In fact the chance of dying on a rail journey equates to about 1 fatality per 500,000 passenger-journeys or a probability of 0.000002 often expressed as 2E-06. Travel by car doubles this risk per journey, and by air the risk is about 6 times greater per journey than by rail (note that aviation safety statistics are massaged to look better by using a kilometre travelled basis to calculate the risk, comfirming most people's gut feeling that air travel is inherently risky!). Crudely stated, the chance of dying as a result of entering hospital is therefore 5000 times greater than on entering a train (2500 times worse than by car and about 1000 times worse than by aircraft per journey). Given all the recent negative publicity about rail safety, this comparison provides, to say the least, cause for reflection on the reasons for adverse events in medical facilities. What happens in a hospital to make it such a dangerous place compared with a train (car, aircraft, etc)? I am currently writing a book about fatal accidents resulting from human error, including medical errors (or adverse events),but in particular looking at the system faults which lead to errors (so-called systemic or system induced errors). Any suggested answers to the above question would be most welcome. Barry Whittingham |
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Joseph Watine Hôpital de Rodez, France
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It seems to me that Barry Whittingham does not bear in mind that, wherever you are (in a train, at home, or anywhere else), if you are critically ill (it is unfortunately the case of many hospitalised patients), you are much more likely to die than if you are healthy (it is fortunately the case of most people who travel by train). In other words: to compare trains with hospitals is quite risky, scientifically speaking. Wouldn’t it be more accurate to compare different hospitals (maybe from different countries) with each other? |
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