Senior health care in rural areas may be lacking

Rural Waianae Coast where many people struggle with finances, cost of medical care and access

Carol Forsloff --It took nearly four hours to get a prescription for Tamiflu and another two hours to bring it home from Kaiser, along with a cost that included insurance support that would make it prohibitive for many elderly people on fixed incomes, which is a problem when influenza protection is particularly important for older folk.  Much of the problem had to do with poor or delayed communication, which can be an issue when Kaiser and other medical facilities have strained budgets and a burgeoning population of the medically needy.

The cost of key medication, especially during flu outbreaks, and the difficulties in obtaining it can create particular problems for the elderly, and most especially the poor elderly in rural areas, such as the Waianae Coast of Oahu in Hawaii.

Experts recommend to avoid summer months for medical procedures

Medical procedure with medication can have errors

Having a medical procedure this summer that is not a vital one?  Perhaps you might reconsider it and schedule it for the fall, because of the issue of medical errors and when they most occur.

Research has established that medical errors are most pat to occur in July.  That was determined in an evaluation of errors and when they most occur in a study conducted in 2010.

that the study determined is that the younger, less experienced doctors are often the ones who fill in for more seasoned physicians in the summer.  The experienced doctors take their vacations during that time, leaving those who are still in somewhat of the learning period to fill in.

Research has found in a University of California study that analyzed 244,388 death certificates issued between 1979 and 2006 listing medication errors as the cause of death, that the rates increased by 10 % in July.  These medicationn errors include:

- Accidental overdose

- Incorrect drug prescribed or taken by mistake

- Incorrect use of drugs during medical or surgical procedures

This increase was only found in areas containing teaching hospitals, and medication errors were the only medical mistakes associated with such a significant increase in fatalities.

Some of those who have examined this issue observe that there should be a balance and staggered process in how doctors are assigned to work and when.

When inexperienced doctors are involved, and many of them still in the process of mastering information, new medications may be found unnecessary or inappropriate in some situations, something the more seasoned doctors understand.

As the Food and Drug Administration maintains medication errors occur because of a number of complex factors.  These can include poor communication between medical personnel on a team or between members of the team and the pharmacy professionals.  In addition some drugs have similar names, therefore confusion can occur.  Other issues can involve fatigue on the part of some of those treating the patient when the packaging itself and the print on that packaging may be misread.

In any case, it is generally recommended that those who wish a voluntary medical procedure avoid the summer months when medication errors are less apt to occur, as observed years ago, a tendency that continues today., 

Diagnostic errors in medicine more widespread than thought

Doctor's office where diagnoses occur

Leanne Jenkins--Mistakes happen; we all say that.  But when they are medical mistakes in diagnosis, some people die while others live in misery with illnesses that are treated incorrectly.  So what are the issues with regard to diagnostic problems, and what is being done about them.

Kaiser is one of the large medical groups that has recently observed the importance of getting correct diagnoses and acknowledges that nationwide many deaths and long-term disabilities are caused by physician error.

This year the New York Daily News reported about a woman in New York City who died as a result of multiple medical errors and a delayed cancer diagnosis that spanned a two-year period.  She reported in February 2010 chest pain and went to an emergency hospital room where she was told she had an asthma condition, after an x-ray had been done.

During the next two years the woman was treated by doctors who never looked at the x-ray.  She was back eventually at the same hospital, and it was at that time the x-ray was finally examined.  She did not have asthma but lung cancer in its final stages.  The woman died, and her life could have been saved had the x-ray been examined two years earlier.

In another case a woman was treated for fibromyalgia and what some doctors maintained was an systemic inflammation.  No one suggested a diagnostic workup for diabetes, despite the fact the woman had indicated that with the condition she often suffered fatigue in the mid afternoons.  Fibromyalgia pain is similar to peripheral neuropathy, and fatigue can occur when blood sugar drops, often about two hours after a meal, which would be the mid afternoon.  By the time she was diagnosed with diabetes, she already had glaucoma and other conditions related to diabetes.  Had she been diagnosed earlier, some of these problems could have been alleviated earlier than they were.

These stories are similar to many people, according to Kaiser reports.  The medical group tells us that wrong diagnoses occurs far more often than people think.

In 1991 surveys revealed that 14 percent of all adverse medical events happened as a result of wrongful diagnoses.  Many of these occurred as a result of doctors failing to look at the results of tests that had been ordered.

When errors occur, often doctors don't find out, and the blame for the resulting problems can be shifted to others.  Many of these errors also go unreported.

These are the facts as outlined by The National Center for Policy Analysis:
- 40,500 diagnostic errors that are fatal occur in intensive care units within American hospitals every year.
- Diagnosis errors are more common than errors involving medication and surgery mistakes, affecting 10-20 percent of all medical cases.
- A 2009 study involving 538 diagnostic errors showed that 28 percent of those errors were fatal, caused permanent disability or threatened the life of the patient.
- Many patients fail to take legal action, making it difficult to estimate how many people are victims.
The problems continue because of the culture of blame and the reluctance to report errors.  In order to reduce legal costs in the United States, as well as medical costs, experts remind us how important it is to reduce the errors.  This can be done by both patient and doctor becoming vigilant and the medical professionals willing to take responsibility for the mistakes instead of covering them up or blaming something or someone else.

Medical errors begin with doctors’ offices

If you want to avoid being the victim of a medical error, the first place to be vigilant is your doctor’s office.

[caption id="attachment_4135" align="alignleft" width="300" caption="Doctors office"][/caption]

Research has found that doctor’s offices add to those medical mistakes that can cause harm to health or even death.  4.5 million people are victims of medical mistakes, according to Health Behavioral News, that also tells us to begin with your doctor’s office and check prescriptions and information at that level.  That’s because not only are mistakes made there but the majority of patients go to doctors’ offices before going straight to emergency rooms, especially when they suspect a serious health condition.

Experts maintain to reduce medical mistakes, the doctor and patient has to be more aware of problems that can occur.  Patients need to track their medications, including the side effects as well as the dosage.  Some say the health care system must provide better record keeping and vigilance with coordination electronic medical records so that doctors can share information.

Medical errors account for a large number of deaths each year, with one website claiming that  medical mistakes account for more deaths each year than AIDS, car accidents, breast cancer and airplane crashes combined.  How accurate these findings are may need further investigation, however more and more research is pointing to medical errors as a major problem in medical care.

Kathleen Sebelius, President Barack Obama’s Health and Welfare Secretary, has this to say about the problem, as she has underlined the Administration is taking on the serious problem regarding medical errors.

“We are setting two ambitious goals. In the next three years, we want to reduce preventable injuries in hospitals by 40 percent. And we want to cut readmissions by 20 percent, targeting return hospital trips that shouldn't occur.

Achieving these goals would save 60,000 lives, protect more than 1.5 million patients from complications that would put them back in the hospital, and save $50 billion over 10 years in Medicare costs alone, as well as tens of  billions more across the health-care system.

Healthcare associated infections continue to be a leading cause of death

GHN News Editor - One
of the top ten leading causes of death in healthcare has to do with
infections within hospitals.  In fact there are nearly 2 million HAIs
associated with 100,000 deaths annually.

New

funding of $34 has been provided by the Agency for Healthcare Research
and Quality under Health and Human Services to improve the quality of
care for hospital patients and expand the fight against healthcare
infections in ambulatory care settings, hospitals, end-stage renal
disease facilities and long-term care facilities.

This
new funding will help improve the quality of care delivered to patients
and expand the fight against HAIs in hospitals, ambulatory care
settings, end-stage renal disease facilities and long-term care
facilities.

Hospitals
have been examining infection rates and looking at preventative
measures, but according to AHRQ, there is not enough information
currently available on infections originating in other health care
settings.

"We
know that infections can occur in any health care setting," said
Carolyn M. Clancy, M.D., AHRQ director. “With these new projects, we can
apply what has worked in reducing infections in hospitals to other
settings and ultimately help patients feel confident they are in safe

hands, regardless of where they receive care.”

Key to reducing medical costs is to reduce medical errors

[caption id="attachment_11522" align="alignleft" width="199" caption="Organizing medications - Wikimedia commons"][/caption]

According to a study commissioned by the Society of Actuaries, medical errors and associated problems such as bed sores, infections and complications, cost the United States economy $19.5 billion in 2008, which if reduced could help reduce overall medical care costs.

The cost of medical errors has been found to be nearly 25 percent of the total costs associated with medical injuries.


The study examined insurance claims data in order to make its determinations, covering 1.5 million measurable errors, which they consider to be a
conservative estimate.

The report estimates that medical errors resulted in more than 2,500 avoidable deaths and over 10 million lost days of work. The study indicates the
following estimated costs, as provided by a recent press release from an attorney involved with medical malpractice cases:

-Bed sores, almost always considered to be the result of an error, represented the largest annual error cost, at nearly $3.9 billion

-Post-operation infections followed at $3.7 billion

-Device complications at $1.1 billion, tied with complications from failed spinal surgery

-Hemorrhages cost $960 million

Jim Toole, managing director of MBA Actuaries, Inc., says the report highlights a singular opportunity to improve the overall quality of care.  He is
therefore calling for new federal safety guidelines that would include a mandatory national reporting system.

PR Newswire cites a survey in which 87 percent of actuaries believe that reducing medical errors is an effective way to control health care cost trends
for the commercial population; 88 percent believe this to be true for the Medicare population. 

According to the study measurable medical errors during 2008 resulted in 2,500 avoidable deaths and more than 10 million excess days missed from work
due to short-term disability.  The average cost per medical error is approximately $13,000.  The study found that an estimated seven percent
of inpatient admissions resulted in some type of medical injury.

The five most costly errors to the U.S. economy each year, according to the study, are: -Pressure ulcers, or bedsores

-Postoperative infections

-Mechanical complications related to devices, implants or grafts

-Postlaminectomy syndrome

-Hemorrhages that complicate a procedure

Precautions which are as basic as using checklists can help reduce the risk of medical errors. Even so, thousands of patients can be and are affected
by many different types of medical errors. Victims of anesthesia error, medication errors, wrong site surgeries, or those who have suffered
bedsores or postoperative infections are not uncommon.

Keeping medical costs down, the study reminds folks, is a key factor in stopping medical errors and being vigilant about it is therefore important for
everyone.

Researchers advise medical care groups to report multiple medical errors

GHN News - As medical errors continue to rise, there are recommendations from researchers to help organizations make sure those errors involving multiple patients are disclosed.

The rate of medical error and type are more and more being disclosed to

patients even if they were not harmed by the event.  These events
include not using completely sterilized equipment, exhibiting poor
laboratory control, and equipment malfunctions that can impact the
patient.  The problem is there is not sufficient disclosure about
multiple incidents.

"It's clear that
health care organizations face a dilemma regarding disclosure of
large-scale adverse events – whether these events lead to patient harm
or not," said AHRQ Director Carolyn M. Clancy,
M.D. "It's not always clear how to do that in a way that minimizes risk
to the patient and the organization, but this research can help."

According to researchers from the University of Washington, Seattle,
hospitals and medical centers are reluctant to disclose problems that
have affected many patients.  There are concerns about the psychological
implications in doing so, but the researchers conclude that in most
cases these events should be disclosed.

These are the recommendations offered on how to make those disclosures:

• "Develop an institutional policy.
  Organizations should have a clear set of procedures for managing the
  disclosure process, notifying patients and the public, coordinating
  follow-up diagnostic testing and treatment and responding to regulatory
  bodies.


• Plan for disclosures.
  Disclosures should be made proactively, unless a strong, ethically
  justifiable argument can be made not to do so. The method of disclosure
  may depend on the event, but patients should be informed personally and
  all at the same time.


• Communicate with the public.
  Organizations should assume that media coverage of a large-scale
  adverse event is inevitable. To build public trust, media responses
  should demonstrate the organization's commitment to honesty and
  transparency.


• Plan for patient follow-up.
  Organizations should provide follow-up diagnostic testing and treatment
  to patients affected by the LSAE and address any anxiety caused by the
  disclosure. Patients who have suffered physical harm due to an event
  resulting from a preventable error or system failure should be
  compensated."

Lead  author Denise Dudzinski, Ph.D., an associate professor in the Department of Bioethics & Humanities at the University of Washington explains it is important to have the public trust, which is an essential reason for full disclosure.

"These
disclosures are never easy, but it is critical that organizations invest
the time and resources necessary to learn how to handle these
disclosures effectively,"  concludes researchers.

Surgical infections more serious risk in surgeries than other complications

Carol Forsloff - New research from The Methodist Hospital in Houston finds infection is more common and more deadly than any other type of complication from surgery.  It holds higher risk to a patient than heart attack or clots and those with risk factors for infection should be screened.

Medical personnel need to be better attuned to the potential for infection and make better determination of those more likely to have sepsis, experts say.  Sepsis is a condition caused by a severe infection.  The number of people dying from it has almost doubled in the past 20 years, according to researchers.

”This research shows that hospitals need to identify at-risk patients earlier and implement sepsis screening and early evidence based interventions with vigilance,” said Dr. Laura Moore, surgeonat Methodist and principal investigator for the study. “Hospitals must put in place consistent, effective measures that are easy to implement.”

Severe sepsis is the leading cause of organ failure and mortality in general surgery ICUs. 934,000 people annually get infections.  Risk factors for this include age of patient (over 60), the need for emergency surgery and the presence of certain co-morbidities like diabetes, high blood pressure, cancer or obesity.  

“There’s nothing we can do to change the fact that a patient is over 60, needs emergency surgery or has diabetes, for instance,” said Moore. “But if we understand the risk factors, there are a lot of relatively simple steps we can take to recognize sepsis and intervene early. We can save 10 times more lives addressing sepsis than we do with all the controls in place to prevent myocardial infarction or pulmonary embolisms.”

Moore has designed and implemented an effective sepsis screening tool to use in the surgical ICU that can be easily used by health care providers and that can determine early indicators of the onset of sepis.  These early indicators include heart rate, temperature, respiratory rate and white blood cell count.  These are checked to determine the possibility of sepsis and for these issues to be addressed immediately, often with antibiotics to eliminate the infection.

Don't have surgery in July if you can prevent it

 

[caption id="attachment_4673" align="alignleft" width="300" caption="Natchitoches Memorial Hospital"][/caption]

If you are having elective surgery, don't plan to do it in July because that's the time when more medical mistakes can happen. 

That old joke "What do you call the person who graduated at the bottom of his/her medical school class?" The answer: "Doctor."  or the least experienced on tap while everyone goes on vacation. 

Check the doctor's resume, if you can; because it might just be important.  It isn't funny when it's July, and that may be the doctor you have, because often it is the bottom guy of the class or the one where the ink ids not dry on the medical diploma. 

 

July is the month that new doctors begin their residencies at teaching hospitals across the country. Rumor among more seasoned doctors is that more errors occur at the hands of new graduates throughout the month, thus creating what is called the "July Effect."

A recent study indicates that the July Effect may be more than just a rumor. According to a recent issue of the Journal of General Internal Medicine, the University of California at San Diego studied the July Effect by examining death certificates across the country over 27 years. Researchers determined that fatal medication errors increased by 10 percent in counties with a high number of teaching hospitals during the month of July, suggesting that new residents were to blame.

Besides being inexperienced, residents also are often sleep-deprived because they often have to work 36-hour shifts.  It is during this time many are trying to acclimate to a new system at their residency hospital. But some medical professionals do not think that new residents are solely to blame. July is generally a hectic month for healthcare professionals with not only new doctors, but also new nurses, pharmacists and other newly graduated caregivers.

 

 "There are a lot of new caregivers in July. It's probably a time where there are a lot of health professionals assuming new responsibilities," noted Dr. Joanne Conroy, chief health care officer for the Association of American Medical Colleges.




The July Effect in Effect for Connecticut Man?

 

Connecticut man Stephen Smith entered the hospital on July 3, 2009, for what he thought would be a relatively quick throat surgery. Following the surgery, he began suffering from a heart arrhythmia so his doctor recommended insertion of a pacemaker. The pacemaker surgery lasted 17 minutes, but Smith was left in the hallway, unmonitored, following the procedure while the hospital staff cleaned the operating room. He began to choke on his own saliva. The alarm on the ventilator was not on.

By the time anyone realized what was happening, Smith's brain had been deprived of oxygen for over a half an hour. Subsequently, he went into cardiac arrest and was revived, but remained in a coma for 10 days. He awoke with severe brain damage and now requires 24-hour nursing care.

His wife never really received an explanation of what went wrong. "I kept asking what happened to my husband and they never gave me an answer. All they kept saying was sometimes things happen during surgeries," said Benay Smith.

 

Subsequent to this incident of Smith and because of the seriousness of what happened, an investigation was conducted by the Department of Public Health.  Although their findings did not suggest that Smith's exacerbated condition was a result of new residents or nurses, it did cite the hospital for 10 separate violations of the health code in Smith's situation. The hospital has since enacted a new policy requiring nurses to stay with patients on ventilators.

 

So far studies only seem to indicate a pattern in the increase of medication errors that occur during July as opposed to surgical errors. According to researcher/anesthesiologist Allen Bashour who is part of a medical error study at the Cleveland Clinic, "You can have surgery on a Friday afternoon in July and have the same outcome as on a Tuesday morning in October."

While human error will always exist, hospitals have begun taking measures to help combat the so-called July Effect. Many teaching hospitals are providing better supervision of residents and have implemented new policies to prevent mistakes made because of sleep deprivation. Other hospitals are looking at ways to continue prevention -- such as using computer software to check for prescription and dosage errors.

 

Staying Safe in Hospitals: Measures You Can Take to Prevent Errors

 

Regardless of when your hospital visit is scheduled, there are certain safety measures you can take to protect yourself from medical mistakes so you don't end up with a medical problem and having to call an attorney about medical malpractice.  As one attorney indicates, there are certain things you need to do to prevent a problem:

- Question what is in every medication you are given, and if you are unsure why you are getting it -- speak up.

- Bring a medical buddy or advocate to the hospital with you. Have relative or friend who can look out for your best interests. Keep them with you at all times so they can speak on your behalf and keep a written record of what the doctor has told you -- especially when you are under the influence of painkillers or drugs that make you groggy.

- Choose a hospital that has the latest technology. Many hospitals have barcode scanners that are used to check patient ID bracelets and medication labels to make sure the proper medication is being administered.

- Carry copies of your own medical records. You have the right to request these from all of your doctors. Your medical information is what a doctor uses to make an accurate diagnosis and often no one doctor has all of it, so if you can provide that information it will reduce the risk of error. Put together a file or binder with your records and include a list of your medications.

- Follow up with your doctor before you leave the hospital. Most hospitals will not have a discharge summary (a summary of everything that happened while you were in the hospital) prepared for you before you leave, but you can still make sure you have all of the information you need for now. Ask your physician to write down dosage information for any new medications -- including the purpose of the medication and how often it must be taken.

 

Finally, it is important to follow up with any tests that have been administered, and request extra copies of lab reports and test results.

 

While steps can be taken to help prevent hospital errors, mistakes still happen. If you have been injured as a result of medical negligence, such as a surgical error or medication misdiagnosis it is important to contact an experienced personal injury attorney.

 

 

 

 

Growing medical errors include risks from anesthesia

Editor -While the risks of anesthesia have been substantially reduced by new safety improvements, statistics show it continues to be a high risk activity that advocates in good medical care stress need to be understood. 

 First of all, it is important to remember that patient consent forms mention the risks of anesthesiology and ask patient permission as its misuse can result in life-altering injuries. 

According to professional anesthesiologists (ASA), complications as the result of anesthesia may include blindness, infection, damage to veins or arteries, damage to a patient's mouth, teeth or vocal chords, lung, heart or blood pressure complications, seizure or stroke, allergic reactions, nerve damage, awareness of the operation, or even death. 

On the other hand, the Mayo Clinic underlines that most people do fine with anesthesia, in spite of the risks.  Still it is important to know what can happen, because medical errors have been growing as a result of the growing number of people seeking services and more and more people needing attention. 

Hospitals are also under scrutiny from medical mistakes.  Several years ago a study was done to track these mistakes, finding in 2004 195,000 people a year die frommedical errors.  Errors can happen during anesthesia also. 

 

These risks are not spread equally across all patients and forms of anesthesia. Instead, each form of anesthesia carries unique risks.

- General Anesthesia: When a patient is under general anesthesia, he or she may face a variety of problems, including aspiration.

- Nerve Blocks: Nerve blocks are one form of regional anesthesia, wherein an injection is placed near a nerve to prevent the nerve from transmitting pain. If the needle is placed directly into the nerve, the injection can cause long-term nerve damage.

- Spinal Anesthesia: Spinal anesthesia (also known as an epidural) is a particular form of a regional anesthesia, used in procedures involving the lower body, abdomen or pelvis. With any regional anesthesia, there is a threat of systemic toxicity if the anesthetic is absorbed into the body through the bloodstream.

- Local Anesthesia: Errors with local anesthesia are uncommon, but in rare cases a patient may suffer an allergic reaction from local anesthesia.

In addition to these specific risks related to anesthesia, all medical procedures come with general risks. Doctors may misread charts and take the wrong approach to a procedure. Nurses may administer the wrong drugs in advance of a procedure, resulting in dangerous drug interactions. Drugs may be mislabeled, and the wrong drug can produce negative results.

Ultimately, the likelihood of any of these injuries or serious complications is very rare. Particular statistics are difficult to obtain, because it is often difficult to determine a single cause of death or injury.

However, according to an article published for the ASA, only about 1 in 150,000 to 1 in 250,000 relatively healthy people die as a result of anesthesia. These rates are likely elevated for those with particular illnesses, such as medical conditions affecting the heart, lungs or kidneys, as well as for the elderly.

In the vast majority of cases, doctors handle their responsibilities as expected and they are able to avoid any injuries from anesthesia by paying close attention to the patient and responding as complications arise.

When problems do arise, the consequences can be life-altering. It is of little consolation to the husband who has lost his wife that deaths from anesthesia are rare.

 

Attorneys  like Michael Watkins tell us, "These injuries are not necessarily avoidable; at times, medical conditions require surgery and the need for the surgery outweighs the risks of problems with anesthesia. However, it is important to work with a knowledgeable doctor and understand the full extent of the risks before surgical procedures," while medical experts agree vigilance in medicine should be practiced also by patients to avoid becoming a statistic.

 

 

 

 

 

 

 

 

 

Problems in Medicine: physician incompetence , under reporting, errors

 

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Carol Forsloff - Attorneys often claim when they are involved in a lawsuit with a doctor, that physicians hang together when it comes to testifying against each other or even supporting patient claims of bad medicine against a doctor, and new research supports to some extent that is true. 




In a survey of doctors, most doctors were found to support the idea of reporting incompetent or impaired folks in the medical profession but when faced with doing so many do not follow through.  

“Many states have mandatory reporting statutes, requiring physicians and other health care professionals to report to appropriate authorities those physicians whose ability to practice medicine is impaired by alcohol or drug use or by physical or mental illness,” researchers say.  

Data  shows the rate of reporting is significantly lower than it should be, given what is said to be the estimated numbers of physicians who become impaired or who are otherwise incompetent to practice. 

Catherine M. DesRoches, Dr.P.H., of Massachusetts General Hospital, Boston, and colleagues did a study to examine doctor's beliefs, actual experiences and level of preparedness involving impaired or incompetent physicians in a survey of 1,891  physicians practicing in the United States in 2009.  The results tell the story of how physicians actually respond when faced with having to file a report. 

The survey found 64 percent of those surveyed agreed that impaired or incompetent physicians should be reported and 17 percent said they had actual knowledge of someone in their group with these issues but only 67 percent of these doctors actually filed a report about their colleagues or others they knew had impairments in the practice of medicine. 

Minority physicians were significantly less likely than other physicians to report, as were international medical graduates compared with graduates of U.S. medical schools.   Big city doctors were more likely to report than those in small practices. 

Most physicians said the reason they didn't report is they felt someone else was handling the problem, along with believing nothing would happen if they did file a report or that there would be retribution. 

“These national data regarding physicians’ beliefs, preparedness, and actual experiences related to impaired and incompetent colleagues raise important questions about the ability of medicine to self-regulate. More than one-third of physicians do not completely support the fundamental belief that physicians should report colleagues who are impaired or incompetent in their medical practice. This finding is troubling, because peer monitoring and reporting are the prime mechanisms for identifying physicians whose knowledge, skills, or attitudes are compromised,” the researchers say. 

These statistics, when combined with the growing rate of medical errors found in research done over the past ten years shows a serious issue in medicine, according to those involved in collecting the data.  The Institute of Medicine looked at the problem in 1999 and found this:

"Between 45,000 and 98,000 Americans die each year as the result of medical errors. If the lower figure is used as an estimate, deaths in hospitals resulting from medical errors are the eighth leading cause of mortality in the United States, surpassing deaths attributable to motor vehicle accidents (43,458), breast cancer (42,297), and AIDS (16,516). Moreover, these figures refer only to hospitalized patients; they do not include people treated in outpatient clinics, ambulatory surgery centers , doctors' or dentists' offices, college or military health services, or nursing homes . Medical errors certainly occur outside hospitals; in 1999, the Massachusetts State Board of Registration in Pharmacy estimated that 2.4 million prescriptions are filled incorrectly each year in that state—which is only one of 50 states.

In the case of physician involvement in reporting incompetence, some of the suggestions for improving physician reporting made by the researchers , as published in the latest edition of JAMA, include strengthening external regulation, making sure reporting systems protect confidentiality and to make sure that those who do report get confidential feedback of the outcomes of any actions taken. 

“All health care professionals, from administrative leaders to those providing clinical care, must understand the urgency of preventing impaired or incompetent colleagues from injuring patients and the need to help these physicians confront and resolve their problems. The system of reporting must facilitate, rather than impede, this process. Reliance on the current process results in patients being exposed to unacceptable levels of risk and impaired and incompetent physicians possibly not receiving the help they need,” the authors conclude.