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Medical Errors: Not following established guidelines
In General Hypertension Cholesterol Asthma Diabetes Heart Attack Heart Failure
The Quality of Health Care Delivered to Adults in the United States

N Engl J Med  2003  June 26   348(26) :2635-45

Review of the medical records for over 4600 patients in 12 cities showed that only 55% of recommended care was provided.

Particular lapses in care included:
Underuse of Screening: Alcohol abuse, Breast Cancer, Colon cancer; Sexually Transmitted Diseases; Evaluation of Low Back Pain
Underuse of Established Treatments: Diabetes; Asthma; Stroke; Congestive Heart Failure; Coronary Aretery Disease; Headache; Hip Fracture;
Cholesterol; Influenza Vaccination; Smoking & Alcohol Cessation Counseling
Overuse of Therapies: Nifedipine after Myocardial Infarction; Prolonged Bedrest in Back Pain

Clinical Research to Clinical Practice — Lost in Translation?

N Engl J Med

August 28, 2003    349(9):868-874.

Author Claude Lenfant examines the gap between medical knowlegde and medicine as it is practiced.


Inadequate management of blood pressure in a hypertensive population.

N Engl J Med 1998 Dec 31;339(27):1957-63

Center for Health Quality, Outcomes, and Economic Research, Bedford Mass. Veterans Affairs Hospital

Physicians in VA medical center failed to treat at least 40 % of patients according to established gudelines.

Failure of evidence-based medicine in the treatment of hypertension in older patients.

Gen Intern Med 2000 Oct;15(10):702-9 (Free Full Text )


Analysis of the degree of undertreatment of hyperlipidemia and congestive heart failure secondary to coronary artery disease.

Am J Cardiol 1999 May 1;83(9):1303-7

Current practice patterns in the management of CAD and CHF are inadequate.


Inadequate therapy for asthma among children in the United States.

Pediatrics 2000 Jan;105(1 Pt 3):272-6

Most children with moderate to severe asthma in this nationally representative sample, including those with multiple hospitalizations, did not receive adequate asthma therapy.

Acute asthma: observations regarding the management of a pediatric emergency room.

Pediatrics 1989 Apr;83(4):507-12

Inadequate assessment and inappropriate treatment of acute asthma have been implicated as contributing factors in morbidity and even deaths, the management of acute asthma, as practiced in an emergency room.

Myocardial Infarction

Treatment of myocardial infarction in the United States (1990 to 1993).

Rogers, et. al., Circulation, 1994 Oct; 90(4):2103-14

Management of myocardial infarction in the United States does not yet conform to clinical trial recommendations.

Underuse of aspirin in a referral population with documented coronary artery disease.

Califf RM, et. al.; Am J Cardiol. 2002 Mar 15;89(6):653-61.

Despite substantial evidence that antiplatelet therapy saves lives and reduces adverse events in patients with coronary artery disease (CAD), use of the most widely available and lowest cost antiplatelet agent, aspirin, continues to be disappointingly low.

The underutilization of cardiac medications of proven benefit, 1990 to 2002.

Stafford RS, Radley DC; .J Am Coll Cardiol. 2003 Jan 1;41(1):56-61.

Both national datasets demonstrate continuing underutilization of warfarin in atrial fibrillation (AF), beta-blockers and aspirin in coronary artery disease (CAD), and angiotensin-converting enzyme inhibitors (ACEIs) in congestive heart failure.. Although use is increasing, it remains lower than expected, and some increases noted in earlier years have slowed. Substantial public health benefits would result from further adoption of these effective therapies.


Frequency of Inappropriate Metformin  Prescriptions.

JAMA Vol. 287 No. 19,  May 15, 200

Institutional review of 100 metformin prescriptions showed 22 patients with absolute contraindications (CHF or renal insufficiency).

Adherence to 1997 diabetes screening guidelines in a large ambulatoryclinic

Koll E, Hewitt JB.; Diabetes Educ 2001 May-Jun;27(3):387-92

Only 57% of patients in large midwestern clinic screened for diabetes according to guidelines.

Congestive Heart Failure

Underutilization and clinical benefits of angiotensin-converting enzyme inhibitors in patients with asymptomatic left ventricular dysfunction .

Am J Cardiol 2000 Sep 15;86(6):644-8

Underutilization of ACE inhibitors in patients with congestive heart failure.

Drugs 2001;61(14):2021-33

Despite abundant evidence to support their efficacy and cost-effectiveness, angiotensin-converting enzyme (ACE) inhibitors are sub-optimally used in patients with CHF.

The 1999 Institute of Medicine Report concluded that from 44,000 to 98,000 people die annually due to errors in inpatient hospital treatment. Hundreds of articles on medical errors have cited the Institute of Medicine Report.

According to Dr. Lucien Leape, lead author of the Harvard study, the number of deaths from medical errors in hospitals account for the equivalent to the death toll from three jumbo jet crashes every two days. Public Health Reports 1999; 114: 302-317 July / August, 1999. One in every 10 patients admitted to a hospital is the victim of at least one mistake. National Public Radio (NPR) November 21, 2000 ,(Audio)

Only 1.53 percent of patients who were harmed by medical treatment filed malpractice claims.

N Engl J Med 1989 Aug 17;321(7):480-4

The I.O.M. based its conclusion on two reviews of hospital charts from New York (1984) and Colorado/Utah (1992).

In 1991, the Harvard School of Public Health studied 1984 data from 51 New York hospitals found that 3.7% of hospital admissions had an adverse event due to medical error and 13.6% of those errors resulted in death. A similar study of hospitals in Utah and Colorado found 2.9% of hospital admissions had an adverse event due to medical error and 6.6% of those errors resulted in death. Extrapolating to the number of hospital admissions in 1997 (33,600,000), the IOM arrived at the highly cited estimates for the upper and lower bounds for deaths due to hospital errors.

The complete text of the Insensitive of Medicine study is available online:

To Err Is Human: Building a Safer Health System

Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, Editors