Iatrogenic and Nosocomial:
Fearful words...Fearful Consequences!

Is your doctor, caregiver, hospital or clinic guilty of Iatrogenic deaths?

"I don't believe I ever killed a man that didn't deserve it", spoken by John Wayne in "The Shootist" (his last film).

How many doctors, nurses and care givers can make that statement?

Let's learn a couple of new words that both refer to the broad range of medical mayhem inflicted on patients by their caregivers; "nosocomial" and "iatrogenic", and then look at their significance.

The term "nosocomial" comes from two Greek words: "nosus" meaning "disease" + "komeion" meaning "to take care of." Hence, "nosocomial" should apply to any disease contracted by a patient while under medical care.

However common usage of the word now refers to hospitals and specifically hospital acquired infection.

"Iatrogenic" is usually used in conjunction with "deaths" as in "Iatrogenic Deaths". In general usage, it refers to deaths inadvertently caused by a doctor, surgeon or by medical intervention or diagnostic procedures.

In plain English, that means that I go to my doctor, get a prescription, turns out it’s a wrong prescription, I take it and die. Or, it's the right prescription, the pharmacist makes a mistake, I take it and die.

Or, I go to the hospital for a minor surgery, I catch one of the antibiotic resistant Superbugs, nothing kills it and I die. Or, during that minor surgical procedure, the surgeon's hand slips, I bleed to death.

Photo: Let's just bury our mistakes

The commonality in all these scenarios is that they were the result of mistakes made by health providers and in each case, I'm just as dead.

Let's find out how often situations like these and others occur.

According to Death by Medicine, a study done by Gary Null, PhD; Carolyn Dean, MD; Martin Feldman, MD; Debora Rasio, MD; and Dorothy Smith, PhD; there are 783,936 iatrogenic deaths at the hands of health providers through errors or negligence each year.

The study has been severely criticized by many doctors and other health providers as being biased and slanted toward the worst possible scenario.

The main criticisms stem from the fact that Dr. Null is a naturopath and sells natural remedies on his website. Strangely, I have never seen the figures in the report attacked; just Null and his collaborators.

Dr. Null and his co-authors may be right on the mark. Their report is well documented with 152 references which gives it a great deal of credibility. I am more inclined to accept their figures as accurate than dismiss them.

The concern I have is that when I see someone deeply involved in alternative and natural cures attacking the healthcare system, especially if that person sells his own products, books, and hosts talk shows, I too tend to be a little skeptical.

I would have no reservations if such a report were published by someone with no personal financial interest in the shortcomings of the healthcare system, that is, no ax to grind.

Some of the more vigorous attacks on the iatrogenic and nosocomial incidents in "Death by Medicine" and Dr. Null, come from Dr. Stephen Barrett who heads up Quackwatch and chairs several consumer advocate groups.

Dr. Barrett is a retired psychiatrist with a long Curriculum Vitae (resume) and presumably is respected in his field.

I have read many reviews, critiques and assessments by Dr. Barrett (mostly on Quackwatch) and I have come to believe that he never met a prescription drug he didn't like or a nutritional supplement or natural cure that he didn't hate.

If Dr. Null is not exactly unbiased, I suspect neither is Dr. Barrett.

The Death by Medicine starts with figures from the first Iatrogenic and Nosocomial study published in 1994 by Dr. Lucian L. Leape in his paper, "Errors in Medicine," and brings it forward to the time period between 2002 and 2003.

The mortality tables appearing in the Null report are apparently based on projections using the foundation laid by Dr. Leape.

As there are no dates appearing on the tables, it is difficult to pin the figures down to a specific year.

Nevertheless, the figures are astounding and indicate that the US healthcare system is directly responsible for more deaths than any other cause, including cancer and heart disease.

The figures are estimates based on inputs from several sources, all tied back to a specific reference. The first table, presumably for the year 2001, shows that:

• Adverse Drug Reactions caused 106,000 deaths
• Medical errors were responsible for 98,000 deaths
• Infection from bedsores caused another 115,000 deaths
• Other infections accounted for 88,000 deaths
• Malnutrition claimed 108,000 lives
• Outpatient deaths killed 199,000 people
• Unnecessary procedures caused 37,136 deaths
• Surgery related mistakes added 32,000 deaths

The grand total of all this was 783,936 deaths inflicted on patients by the healthcare system.

I am assuming the totals were for 2001 since a comparison of cancer and heart deaths was given for that year.

There were 553,251 cancer deaths and 699,697 heart fatalities in 2001; both under the estimated iatrogenic and nosocomial deaths.

Let's see if we can find more recent numbers for those iatrogenic and nosocomial deaths.

Regarding infections, especially infections acquired while in the hospital, a January 2007 report in the AARP Bulletin reports that one in twenty people who go into a U.S. hospital pick up an infection.

Worse, for 90,000 Americans a year, that infection results in death, another iatrogenic statistic. That's a bit higher than the Death by Medicine figures.

To put it in perspective, that one in twenty that gets an infection translates to 2 million patients. Doing the math, 40 million people go into a U.S. hospital each year, 2 million get an infection, 90,000 of them die.

Well, that’s only .225% of the people getting hospitalized that die from an iatrogenic or nosocomial infection. What's .225% anyway?

Dr. Betsy McCaughey, in her recent book, "Unnecessary Deaths: The Human and Financial Costs of Hospital Infections, 2nd Edition" places the figure at "103,000, as many as AIDS, breast cancer and automobile accidents combined".

Furthermore, she reports that it is all preventable by instilling an unyielding dedication to good hygiene in our hospitals.

To add credence to the figures, a September 17, 2008 article in the Wall Street Journal reported that 500,000 cases of hospital infections are from one bacteria superbug, the Clostridium difficile.

Photo right: Superbug Clostridium difficile

Somewhere between 15,000 and 30,000 iatrogenic deaths occur each year from this organism alone.

What if we had 90,000 combat deaths in Iraq per year? I think the "stuff" would hit the fan pretty fast. Congress would call for investigations, generals would be fired, we would be "outta" there in the blink of an eye. Something very wrong here.

From the May 8th, 2005 issue of Science Daily, we read that adverse drug and device reactions account for as many as 100,000 iatrogenic deaths annually.

Unfortunately, more than half of the most serious adverse drug reactions have not been discovered until seven or more years after a drug has been marketed.

The article goes on to say that a monitoring program developed by a Northwestern University researcher has identified a large number of previously unknown, serious and often-fatal drug reactions associated with 15 commonly used drugs, including Plavix®, thalidomide and drug-coated cardiac stents.

From the Injury Board in Tampa, FL we read that "The American College of Allergy, Asthma, and Immunology" reports that adverse drug reactions account for an estimated 106,000 iatrogenic deaths each year in the United States, alone". Click on the book cover on the right for a good reference on the subject.

They also state that "very few adverse events are actually reported to the FDA. It is estimated that less than 1% of all adverse events get reported to the FDA, but these adverse events serve as a basis for intense study to evaluate whether a drug is safe or not."

The Injury Board is a community of attorneys, media professionals, safety industry experts, and local activists helping families stay safe and avoid injury, and helping those who are injured get the assistance they need to move on with their lives after an accident.

According to the Death by Medicine study, bedsores kill 115,000 each year. This is an iatrogenic phenomenon seen mostly in nursing homes or anywhere patients are bedridden or confined to a wheelchair.

Infection from bedsores in entirely preventable and represents the first visible evidence of nursing home abuse.

If any of your loved ones are bedridden in a nursing home and have bedsore infections, get a lawyer. The good news is that the current figures are lower than those reported in the Death by Medicine report so maybe we are getting better in this area.

The Nursing Home Abuse Resource website describes bedsores as an infection that can lead to serious injury and death. They say there are several types of infection from bed sores, also known as pressure sores and decubitis, which a patient can develop when their condition is not promptly and adequately treated.

Photo left: Stage 4 Bedsore (Decubitis)

Each year in the United States about one million people develop bed sores. They develop when the blood supply to the skin is cut off for two hours or more. Approximately 60,000 people die as a result of infection from bed sores. Infection from bed sores occurs when bacteria develops in the affected area. These bacteria can cause significant damage to the skin, blood, bones, muscles, and other tissues in the affected area.

Infection from bed sores is more likely in the presence of sweat, feces, urine, or other moisture when these materials come in contact with affected skin. This is an iatrogenic event resulting from pure neglect and indifference.

The Spokane Review of Spokane, WA reported that in 2006 Medicare logged nearly 323,000 cases of pressure sores as secondary diagnoses and that the average charge to treat the condition was $40,381.

Those figures reiterated a 2006 study by the Agency for Healthcare Research and Quality, which found 455,000 cases of pressure sores in U.S. hospitals in 2003, an increase of 63 percent from a decade earlier.

Photo right: Stage 4 Pressure Sores with protrusion of lower hip bone (Tuberosity of Ischium) shown in small square

The average charge for treating those cases was nearly $37,800, the study showed.

According to the Nursing Home Abuse Resource Center, a law firm specializing in elder abuse in nursing homes, two out of five nursing home residents are malnourished.

Dehydration is cited as the most common fluid and electrolyte disorder of elderly nursing home residents.

Malnutrition in the nursing home environment can occur for a variety of legitimate reasons, including the resident's inability to digest or absorb food and even badly fitted dentures.

Dehydration, likewise, can occur for a variety of physiological reasons as well, including diarrhea or effects of medication. Unfortunately, malnutrition and dehydration can and do also occur due to a nursing home's negligence.

Such negligence is mostly attributable to understaffing which in turn is the result of funding constraints in government or charitable facilities or the cost cutting in private for-profit facilities.

Government statistics show that 47% of residents in nursing homes need assistance with eating. 21% of residents are completely dependent for help. In addition, patients in nursing homes often need more water than the average person because of the medications they are taking.

If the nursing home is understaffed, then there may not be anyone available to take the time to see that the patient has had enough to eat or to drink. Whatever the reason, it is an iatrogenic event in the making.

Testimony presented before investigative bodies has shown that in many nursing homes, time schedules take precedence over the patients’ welfare. In one case, each caregiver were responsible for feeding up to 15 elderly residents in a 45 minute period. Nursing home abuse is possibly the most criminal of iatrogenic occurances.

In this particular home, getting the food carts and trays returned to the kitchen at a certain time resulted in a situation of forced, fast feeding of residents resulting in some not getting fed at all.

Rules and policy issues in an institution can contribute to the occurance iatrogenic events.

As to magnitude of the problem, the Detroit News reported that malnutrition and dehydration killed nearly 14,000 patients from 1999-2002.

This was out of a reported population of 1.6 million people in 16,000 U.S. nursing homes.

Current data on iatrogenic deaths seems to be a rare commodity. When one tries to track down figures on deaths in nursing homes or facilities labeled as "long term care" housing, it is quickly apparent that most entries on the web are citing the same one or two studies, both pre-2002.

The Detroit News item mentioned above appears over and over throughout any literature search. The 16,000 deaths reported accounts for only 15% of the 108,000 deaths claimed by the Death by Medicine study. Where did all those other fatalities come from?

Maybe our nursing homes are getting better. Maybe the numbers are anybody's best guess. More likely, maybe the people conducting the surveys don't know what to look for or, worse, too many deaths are being reported as resulting from some other cause.

I like the last possibility; after all, no healthcare facility wants to be linked to iatrogenic deaths, they tend to attract lawyers. Speaking of lawyers, if you think you might have a medical malpractice case, click on the book cover shown above, Medical Malpractice Claims Investigation" to see how the process works.

There is a December, 2005 Government Accounting Office (GAO) report titled, NURSING HOMES: Despite Increased Oversight, Challenges Remain in Ensuring High-Quality Care and Resident Safety.

It details nursing home survey data from CMS (center for Medicare and Medicaid Services) that shows a significant decrease in the proportion of nursing homes with serious quality problems, from about 29 percent in 1999 to about 16 percent by January 2005.

It goes on to say that this trend masks two important and continuing issues: inconsistency among state surveyors in conducting surveys and understatement by state surveyors of serious deficiencies.

There are no meaningful statistics given but the report does say, "A small but unacceptable proportion of nursing homes repeatedly caused actual harm to residents, such as worsening pressure sores or untreated weight loss, or placed residents at risk of death or serious injury.

I strongly suspect the "Death by Medicine" figure of 108,000 is close to the current annual death rate from malnutrition and dehydration in our nursing homes.

I also suspect that due to the hundreds (maybe thousands) of law firms looking for such cases to prosecute, the numbers are being vastly underreported or the Cause of death being identified as "natural causes".

If you were running a nursing home, it wouldn't do your career much good to have "Death from Malnutrition due to Negligence" showing up on death certificates from your facility, now would it? These are old people after all. How deep is anyone going to dig?

Yes, there are those that are into Complementary and Alternative Medicine who spend a lot of ink reporting iatrogenic events and highlighting the shortcomings of the healthcare system. Chances are, iatrogenic events drive a lot of people to the CAM movement.

Maybe there is balance in the universe, since there are those in the "system" that spend just as much ink hyperventilating about the natural or alternative approach. Granted, scams have permeated the CAM movement and the docs that expose them are doing us all a service.

Unfortunately there are practitioners on both sides that are just plain obnoxious, even toxic, exhibiting such arrogance and sarcasm that it detracts from any positive contribution.

On the medical side, there are far too many that seem to think the "D" in M.D. stands for "Deity".

If you want to see what I mean, check out the "Skeptic" magazine or read a sampling of blurbs in "Quack-Files" on the web.

I see a lot of similarity between the shrill of the CAM'ers and Doc deities and the rantings of the ultra-left and far-right in politics.

It just seems that the whole field of health attracts people with personal agendas or a financial interest in one side or the other. Quality, accurate data is hard to come by but opinions are like armpits, everyone has more than one and they usually smell. At any rate, where iatrogenic events are concerned, mostly they are self inflicted in CAM as opposed to doctor infliced in traditional medicine.

For a good read on a positive blend of traditional and natural medicine, REAL integrative medicine, pick up any of the Mehmet Oz and Michael Roizen books, both are M.D.'s who combine the best of both worlds for the benefit of their patients (and those of us who read their books).

A good one to start with would be "YOU, The Owner's Manual". Another good read on preventative medicine combining both worlds of allotropic and alternative medicine is ULTRA-PREVENTION" by M.D.'s Mark Hyman and Mark Liponis.

Statistical reporting of deaths due to mistakes of the system is somewhat unreliable; it is difficult to know what the exact figures are. Given human nature and the inclination of the system to protect its reputation, it is highly likely that the figures are under-reported if anything.

At any rate, iatrogenic and nosocomial deaths are alarmingly high and certainly cause for concern by anyone facing a hospital stay, surgery, or taking more than one prescription drug.

If I have to take one prescription drug, there may be side effects but add another drug or several drugs and interactions suddenly become a serious concern.

The more drugs one takes, the more likely that side effects will be more unpredictable and severe.

Our people get themselves in a big uproar over 5000 or so deaths in Iraq in almost six years of fighting. These are trained soldiers who volunteered for military duty and knew what they were getting into.

Yet no one except a small handful of people seem to care about the 700,000 or so deaths from medical errors EVERY year in the U.S. and they get crucified when they speak up or try to document it.

Let's see, if 700,000 deaths occurred every year from jetliner crashes you think someone might notice and raise the alarm? After all, that's almost four jumbo jet crashes per day.

Iatrogenic and nosocomial deaths are inflicted on people who trusted the system and never imagined they would end up dead from someone’s mistake or neglect or indifference.

Why does it happen? For some insight, click on the book cover shown above on the right, "Medical Errors and Medical Narcissism".

It examines the concept of “medical narcissism” and how error disclosure to patients and families is often compromised by the health professional’s need to preserve his or her self-esteem at the cost of honoring the patient’s right to the unvarnished truth about what has happened.

People killed or injured by the healthcare system didn't volunteer for hazardous duty, like our military casualties, but they ended up just as dead or wounded. Our healthcare system can serve us better.

Wouldn't it be nice if there was a way to get a rating on hospitals before we check in? How about getting a doctor's report card before making that first appointment? Would you like to be able to check on a nursing home's quality of care and safety performance before signing mom up?

The resources are there, the trick is finding them. A few will be posted here for now and updated from time to time.

There is a company based in Golden Colorado called HeathGrades, Inc. that provides a wealth of information on all aspects of the U.S. heathcare system. Much of the information is free on-line, some reports require payment of a fee.

HealthGrades has a website at www.healthgrades.com in which they describe themselves as "the leading healthcare ratings organization, providing ratings and profiles of hospitals, nursing homes and physicians to consumers, corporations, health plans and hospitals".

"Millions of consumers and hundreds of the nation's largest employers, health plans and hospitals rely on HealthGrades' independent ratings, consulting and products to make healthcare decisions based on the quality of care. Founded in 1999, the firm now has over 160 employees."

I have not personally had a reason to use their services and therefore, can't vouch for the accuracy of their information.

However, they have been featured in numerous media reports, TV news spots,and many national magazines and it would be worth a look before making any major health care decisions.

There are numerous firms providing comprehensive reports on M.D.s throughout the U.S. Most charge a nominal fee of less than $20.00 per report. It could be the best few bucks ever spent if facing any invasive treatment.

A few such firms gleaned from a quick web review found: MDNationwide, requires an account, flat fee per report RateMD.com, requires an account, no fee, Google ad supported HealthGrades, already mentioned above Book of Doctors, free basic information, fee for complete report

These are not recommendations since I have no experience with them. They are only shown as examples of what type of research services are available and there are many more that could have been named.

One of the best places to start researching nursing homes is the Medicare site. Just Google "Nursing Home Ratings" and it will be in the top five listings.

When going on-line to find data on nursing homes, you will have to filter through numerous law firms offering up information. Just remember that they are in business to sue someone; helping you evaluate a nursing home is not their mission in life.

For nursing homes, HealthGrades seems to be another great resource to look into.

The message here is that there is a wealth of information available to anyone. As you have seen, because of the prevalence of iatrogenic events, selection of healthcare facilties and providers can be a life or death decision. A little up-front research, even if a fee is required, could save a life.

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