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Section 5
Preventable Medical Errors

Question 5 | Test | Table of Contents

Preventable medical errors kill and seriously injure hundreds of thousands of Americans every year. Any discussion of medical negligence that does not involve preventable medical errors ignores this fundamental problem. And while some interested parties would prefer to focus on doctors’ insurance premiums, health care costs, or alternative compensation systems—anything other than the negligence itself—reducing medical errors is the best way to address all the related problems. Preventing medical errors will lower health care costs, reduce doctors’ insurance premiums, and protect the health and well-being of patients.

The Institute of Medicine’s (IOM) seminal study of preventable medical errors estimated as many as 98,000 people die every year at a cost of $29 billion.[1] If the Centers for Disease Control were to include preventable medical errors as a category, these conclusions would make it the sixth leading cause of death in America. [2]










Further research has confirmed the extent of medical errors. The Congressional Budget Office (CBO) found that there were 181,000 severe injuries attributable to medical negligence in 2003.3  The Institute for Healthcare Improvement estimates there are 15 million incidents of medical harm each year.[4] HealthGrades, the nation’s leading healthcare rating organization, found that Medicare patients who experienced a patient-safety incident had a one-in-five chance of dying as a result.[5]

In the decade since the IOM first shined a light on the dismal state of patient safety in American hospitals, many proposals for improvement have been discussed and implemented. But recent research indicates that there is still much that needs to be done. Researchers at the Harvard School of Medicine have found that even today, about 18 percent of patients in hospitals are injured during the course of their care and that many of those injuries are life-threatening, or even fatal.[6] The Office of the Inspector General of the U.S. Department of Health and Human Services found that one in seven Medicare patients are injured during hospital stays and that adverse events during the course of care contribute to the deaths of 180,000 patients every year.[7]

Even errors that the government and private health insurers have classified as "never events," events that should never happen in a hospital, are occurring at alarming rates. Recently the Joint Commission Center on Transforming Healthcare reported that as many as 40 wrong site, wrong side and wrong patient procedures happen every week in the U.S.[8] Similarly, researchers in Colorado recently found that surgical "never events", such as operating on the wrong patient or wrong site or performing the wrong procedure, are occurring all too frequently.[9]

Yet despite these numbers, the American public remains unaware of just how pervasive the problem is. Even though one in three Americans say that they or a family member has experienced a medical error, and one in five say that a medical error has caused either themselves or a family member serious health problems or death, surveys show that Americans vastly underestimate the extent of medical errors.[10] About half of respondents believe the annual death total from medical errors to be 5,000 or less—nearly 20 times lower than the IOM’s estimate.

People have been led to believe that there are hundreds of thousands of medical negligence lawsuits every year and only a handful of genuine medical errors. In reality, the reverse is true. There are very few medical negligence lawsuits, and hundreds of thousands dying from preventable medical errors. As University of Pennsylvania law professor Tom Baker puts it, "We have an epidemic of medical malpractice, not of malpractice lawsuits."[11]

Much of the discussion surrounding medical negligence revolves around costs, whether it be the cost of physicians’ insurance or the cost to health care. While these are the subject of much debate and acrimony, the potential savings from the elimination of medical errors are undeniable.

Dollars better spent on patient safety
The Center for Medicare & Medicaid Services (CMS) has, in recent years, recognized the potential for financial savings by reducing medical errors. CMS has stopped paying for hospital and practitioner errors, and thus created a financial incentive for hospitals to embrace patient safety. After evaluating a number of billable hospital-acquired conditions, CMS and the CDC decided on eight expensive but "reasonably preventable" secondary conditions that would not be reimbursed by Medicare, and could not be billed to patients.[12]

Previously, Medicare rewarded hospital errors with larger reimbursements, by paying them an extra amount to treat various preventable complications that developed as a result of hospital negligence. 
The new rules, which went into effect in 2008, are expected to save taxpayers at least $21 million annually and will encourage hospitals to take steps to avoid "reasonably preventable" hospital acquired conditions.[13] Private insurers like Blue Cross/Blue Shield Association and Aetna have also implemented similar policies not to reimburse medical providers for care related to problems or complications that should not occur in the normal course of hospitalization.[14]

Personal Reflection Exercise #5
The preceding section contained information about preventable medical errors.  Write one case study example regarding how you might use the content of this section in your practice.
Reviewed 2023

Detection and Prevention of Medication Errors by the Network of Sentinel Pharmacies in a Southern European Region

Jambrina, A. M., Santomà, À., Rocher, A., Rams, N., Cereza, G., Rius, P., Gironès, M., Pareja, C., Franch, À., & Rabanal, M. (2022). Detection and Prevention of Medication Errors by the Network of Sentinel Pharmacies in a Southern European Region. Journal of clinical medicine, 12(1), 194.

Peer-Reviewed Journal Article References:
Katz-Navon, T., Naveh, E., & Stern, Z. (2009). Active learning: When is more better? The case of resident physicians’ medical errors. Journal of Applied Psychology, 94(5), 1200–1209.

O'Donohue, W. T., & Engle, J. L. (2013). Errors in psychological practice: Devising a system to improve client safety and well-being. Professional Psychology: Research and Practice, 44(5), 314–323.

Siddiqi, S., Elasady, R., Khorshid, I., Fortune, T., Leotsakos, A., Letaief, M., Qsoos, S., Aman, R., Mandhari, A., Sahel, A., El-Tehewy, M., & Abdellatif, A. (2018). "Patient Safety Friendly Hospital Initiative: From evidence to action in seven developing country hospitals": Corrigendum. International Journal for Quality in Health Care, 30(7), 576.

Teachman, B. A., White, B. A., & Lilienfeld, S. O. (2021). Identifying harmful therapies: Setting the research agenda. Clinical Psychology: Science and Practice, 28(1), 101–106.

Ward, M., McAuliffe, E., Fitzsimons, J., & O'Donovan, R. (2019). Informing healthcare team performance: Integrating data to improve quality and safety. International Perspectives in Psychology: Research, Practice, Consultation, 8(1), 53–56.

What is a Never Event? To select and enter your answer go to Test.

Section 6
Table of Contents

Excerpt from Bibliography

1 To Err Is Human: Building a Safer Health System, Institute of Medicine, 1999
2 Deaths/Mortality, 2005, National Center for Health Care Statistics at the Centers for Disease Control, viewed at
3 Key Issues, Congressional Budget Office, December 2008, 150-154.
4 Institute for Healthcare Improvement: Campaign – FAQs, Institute for Healthcare Improvement, 
5 The Fifth Annual HealthGrades Patient Safety in American Hospitals Study, HealthGrades, April 2008.
6 Christopher P. Landrigan et al., Temporal Trends in Rates of Patent Harm Resulting from Medical Care, New England Journal of Medicine, November 25, 2010.
7 Daniel R. Levinson, Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries, Department of Health and Human Services Office of the Inspector General, November 2010.
8 Wrong Site Surgery Project, Joint Commission Center for Transforming Healthcare.
9 Philip F. Stahel et al., Wrong-Site and Wrong-Patient Procedures in the Universal Protocol Era, Archives of Surgery, 2010;145(10):978-984.
10 National Survey on Consumers' Experiences With Patient Safety and Quality Information, Kaiser Family Foundation, November 17, 2004.
11 Tom Baker, The Medical Malpractice Myth, 2005.
12 Those medical complications not covered were: Object Left in Surgery (Serious Preventable Event); Air Embolism (Serious Preventable Event); Blood Incompatibility (Serious Preventable Event); Catheter-Associated Urinary Tract Infections Pressure Ulcers (Decubitus Ulcers); Vascular Catheter-Associated Infection Surgical Site Infection Hospital Acquired Injuries, including fractures, dislocations, intracranial injury, crushing injury, and burns. See 72 F.R. 47201.
1372 F.R. 47201.
14 Vanessa Fuhrmans, Insurers Stop Paying for Care Linked to Errors, Wall Street Journal, January 15, 2008.