Intended for healthcare professionals

Rapid response to:


Medical error—the third leading cause of death in the US

BMJ 2016; 353 doi: (Published 03 May 2016) Cite this as: BMJ 2016;353:i2139

Rapid Response:

Re: Medical error—the third leading cause of death in the US

BMJ Responses

Response to Aubrey Milunsky:

Research by the Betsy Lehman Center showing that 23% of adults in Massachusetts reported experiencing a diagnostic error in the last five years and the recent Institute of Medicine report “Improving Diagnosis in Health Care” have helped raise awareness about the prevalence of the problem and established a new priority for health care improvement. While medical school curriculum, like our own at Johns Hopkins, are expanding to teach the science of safety, an important part of that culture change is a departure from a blame the individual approach and an evaluation of the how systems can be designed safer. We appreciate the non-technical skills of doctoring that Dr. Milunsky suggests.

Response to Tjaard U. Hoogenraad:

Thank you for this case study demonstrating how an outcome can be non-fatal, yet significant. While we did not focus on non-fatal injury and disability due to medical care gone awry, examples such as these point out the patient-centered approach that is central to any patient safety strategy.

Response to Kaveh G. Shojania:

The very real problem of medical care gone wrong should be measured rigorously with more autopsies and a data collection infrastructure as strong as the one used to generate national cancer statistics each year. But currently that does not exist. In the mean time, we rely on scientific estimates from scientific studies in the literature. We applaud the prior contributions of the Canadian physician and sociologist, but reject their primary argument that they “find it very hard to believe” as a scientific argument. The purpose of science is to extend the validated body of knowledge, which inherently is expected to challenge and even controvert deeply held beliefs. In their own articles, they have frequently cited the 1999 I.O.M. To Err is Human estimate that uses data from 1984 and 1992 (1). In our article, we challenge this establishment estimate, and point out its limitations. While no estimate is perfect, we respectfully submit a more updated estimate that uses better methodology.

The Canadian physician previously wrote that the studies from which the 1999 I.O.M. estimate was derived may not have detected diagnostic errors which in he reported as being found in 8.4% of hospital deaths, or as he extrapolates in his article, 71,400 deaths of the 850,000 deaths in the year of his research study (2). Simply adding his own estimate to the 1999 I.O.M estimate would rank the incidence of death from medical error well above the #3 cause of death that year.

While the Canadian physician and sociologist cite studies to arrive at their current estimate of 25,200 annual deaths from medical error (far below the estimate of the I.O.M. To Err is Human Report), the rates described in the our analysis are based on rigorous scientific studies published in the New England Journal of Medicine, Health Affairs, and the independent Medicare OIG report, all of which have been cited and affirmed by several recent Institute of Medicine Reports, and also in the recent study by John James that suggests our estimate may be low. When there is a pattern of literature supporting the incidence we describe, it should be considered in good faith. While the media is known to polarize people, it is our hope that we can be constructive. We can learn from your primary care and sociology vantage points respectively, and invite you to attend our surgical morbidity and mortality conference as we do each week. Given the number of lives ruined by disability and death due to medical care gone wrong, we believe a more scientific conversation, rather than a territorial one, helps put the focus on solutions.

Today in the U.S., there are more medications, diagnoses, procedures, and handoffs performed than ever in the history of medicine. Moreover, overtreatment is now an endemic problem in some areas of medicine. With more medical care being delivered, there are naturally more opportunities for things to go wrong. In fact, harm may be associated with complexity. The Commonwealth Fund reported that the U.S. leads the world in medical errors, observing that 34% of patients with health problems in the U.S. report experiencing medical, medication, or test errors—the highest rate of any nation (3). We believe a systems approach, rather than a blame the doctor or shoot the messenger approach, is the best path to a safer health care system. An honest conversation without obvious and apparent bias about the best available science is an important prerequisite to addressing the problem.

1. To err is human: building a safer health system . Washington, DC: National Academy Press, Institute of Medicine; 1999.

2. Shojania KG, Burton EC, McDonald DM, Goldman L., Changes in rates of autopsy-detected diagnostic errors over time: a systematic review. JAMA 2003;289(21):2849-56.
3. The Commonwealth Fund:

Response to Daniel J Baldor

In our study, we reported a range in addition to a point estimate. We agree with medical students Baldor and Kravietz in their final conclusion that after their self-described adjustment, “medical errors remain the third leading cause of death medical error”. The proportion of adverse events that are preventable depends on several factors and for that reason there is no quick fix to “correct” for differences in study methodology when reconciling different studies.

Response to John T. James

We agree with Dr. James and consider his 2013 article in the Journal of Patient Safety, cited in our analysis, to be an important contribution to the field. While it suggests that our estimate may be low, we all recognize that none of the studies mentioned captured outpatient surgery deaths or deaths at home due to medical error. Thus we recognize that the true death toll from medical care gone wrong is likely higher.

If the house is on fire, we should ask “How can we put out the fire?” Discussing differences about what is the best scientific estimate of the fire’s temperature can be paralyzing for some. We appreciate Dr. James’ scientific work, detailed in his comment, coupled with his tremendous advocacy work in the field.

Response to Linda Williams:

We applaud the your efforts and those of the Director of the National Center for Patient Safety and agree with your response pointing out that the vast majority of errors are system errors. In defining medical error as we did in our article to include both a system error and an individual error, it created a territorial discussion around nomenclature. Our definition is best summarized in the notion that people can die from the care they receive rather than from the disease or injury that brings them to care. We believe the data is best discussed with a patient-centered lexicon as you explain from your experiences.

Response to Dr. Gallie:

Anesthesiology has long been at the forefront of patient safety. We agree and recognize that there is a lot of work that needs to be done to address the many contributing factors to the problem of medical care gone wrong. Patient safety tools are one step. Addressing unwarranted clinical variation around best practices in the context of a culture of safety is another. Recognizing that we have a problem is an important prerequisite.

Response to Dr. Ghirardini:

The Bristol events highlight both the ubiquitous and compartmentalized nature of the problem. More globally, a discrete two-tiered health care system is forming. Patients are often referred to as “private patients” or “public hospital patients”. Disparities in quality, safety, overtreatment, and undertreatment can vary markedly within this these two health care systems. Similarly, one’s perspective on patient safety can be skewed by the tier in which they practice. We agree with the physician’s strategy towards a better health care system for all.

Response to Dr. Cohen:

We agree that working towards a culture of safety and teamwork is an important context for many of the solutions mentioned. Thank you for sharing your clinical and leadership experiences.

Competing interests: No competing interests

15 July 2016
Martin A. Makary M.D., M.P.H., F.A.C.S.
Professor of Surgery and Health Policy & Management,
Michael Daniel MD
Johns Hopkins University School of Medicine
600 N. Wolfe St, Halsted 610