A study by researchers at Johns Hopkins Medicine says medical errors should rank as the third leading cause of death in the United States — and highlights how shortcomings in tracking vital statistics may hinder research and keep the problem out of the public eye.

The authors, led by Johns Hopkins surgeon Dr. Martin Makary, call for changes in death certificates to better tabulate fatal lapses in care. In an open letter, they urge the Centers for Disease Control and Prevention to immediately add medical errors to its annual list reporting the top causes of death.

Based on an analysis of prior research, the Johns Hopkins study estimates that more than 250,000 Americans die each year from medical errors. On the CDC’s official list, that would rank just behind heart disease and cancer, which each took about 600,000 lives in 2014, and in front of respiratory disease, which caused about 150,000 deaths.

Medical mistakes that can lead to death range from surgical complications that go unrecognized to mix-ups with the doses or types of medications patients receive.

But no one knows the exact toll taken by medical errors. In significant part, that’s because the coding system used by CDC to record death certificate data doesn’t capture things like communication breakdowns, diagnostic errors and poor judgment that cost lives, the study says.

“You have this overappreciation and overestimate of things like cardiovascular disease, and a vast underrecognition of the place of medical care as the cause of death,” Makary said in an interview. “That informs all our national health priorities and our research grants.”

The study was published Tuesday in The BMJ, formerly the British Medical Journal.

Bob Anderson, chief of the mortality statistics branch for the CDC, disputed that the agency’s coding is the problem. He said complications from medical care are listed on death certificates and that codes do capture them.

The CDC’s published mortality statistics, however, count only the “underlying cause of death,” defined as the condition that led a person to seek treatment. As a result, even if a doctor does list medical errors on a death certificate, they aren’t included in the published totals. Only the underlying condition, such as heart disease or cancer, is counted, even when it isn’t fatal.

Anderson said the CDC’s approach is consistent with international guidelines, allowing U.S. death statistics to be compared with those of other countries. As such, it would be difficult to change “unless we had a really compelling reason to do so,” Anderson said.

The Johns Hopkins authors said the inability to capture the full impact of medical errors results in a lack of public attention and a failure to invest in research. They called for adding a new question to death certificates specifically asking if a preventable complication of care contributed.

“While no method of investigating and documenting preventable harm is perfect,” the authors write, “some form of data collection of death due to medical error is needed to address the problem.”

Anderson, however, said it’s an “uncomfortable situation” for a doctor to report that a patient died from a medical error. Adding a check box to the death certificate won’t solve that problem, he said, and a better strategy is to educate doctors about the importance of reporting errors.

“This is a public health issue, and they need to report it for the sake of public health,” he said.

Dr. Tejal Gandhi, president of the National Patient Safety Foundation, said her organization refers to patient harm as the third leading cause of death. Better tracking would improve funding and public recognition of the problem, she said.

“If you ask the public about patient safety most people don’t really know about it,” she said. “If you ask them the top causes of death, most people wouldn’t say ‘preventable harm.’ “

Dr. Eric Thomas, a professor of medicine at the University of Texas Houston Medical School whose research was cited in the Institute of Medicine’s landmark To Err is Human report, said existing estimates aren’t precise enough to support immediately listing errors as the third leading cause of death.

But collecting better cause-of-death data is a good idea, said Thomas, who agreed that medical errors are underreported.

“If we can clarify for the public and lawmakers how big a problem these errors are,” he said, “you would hope it would lead to more resources toward patient safety.”

Have you or a loved one been harmed during medical care? Join the discussion at ProPublica’s Patient Safety Facebook group or fill out the Patient Harm Questionnaire.

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At some hospitals, posters on the wall in the emergency department list the drugs that are in short supply or unavailable, along with recommended alternatives.

The low-tech visual aid can save time with critically ill patients, allowing doctors to focus on caring for them rather than doing research on the fly, said Dr. Jesse Pines, a professor of emergency medicine and director of the Office for Clinical Practice Innovation at the George Washington University School of Medicine and Health Sciences. He has studied the problems created by shortages.

The need for such workarounds probably won’t end anytime soon. According to a new study, shortages of many drugs that are essential in emergency care have increased in both number and duration in recent years even as shortages for drugs for non-acute or chronic care have eased somewhat. The shortages have persisted despite a federal law enacted in 2012 that gave the Food and Drug Administration regulatory powers to respond to drug shortages, the study found.

For this report, which was published in the May issue of Health Affairs, researchers analyzed drug shortage data between 2001 and 2014 from the University of Utah’s Drug Information Service, which contains all confirmed national drug shortages, according to the study.

They divided the drugs into acute and non-acute categories. Acute-care drugs were those used in the emergency department for many of the urgent and severe conditions handled there and include remedies such as pain medications, heart drugs, saline solution and electrolyte products.

Overall, the study found that 52 percent of the 1,929 shortages during the time period studied were for acute-care drugs. Following passage of the federal law in 2012, the number of active shortages of non-acute care drugs began to decline for the first time since 2004, but there was no corresponding dropoff in shortages of drugs that emergency departments and intensive care units rely on, the researchers reported.

Shortages of the drugs for emergency care lasted longer as well, the study found. Half of the shortages of drugs for acute care lasted longer than 242 days, compared with 173 days for non-acute care drugs.

Seventy percent of the drugs that were difficult to get were injectable drugs, which emergency departments rely on to a much greater degree than other types of providers. The most common acute-care drugs affected were those to fight infections, such as antibiotics; those that affect the central nervous system, including painkillers and sedatives; and the drugs that suppress or stimulate the autonomic nervous system, which controls heart and breathing rates.

When patients come to the emergency department who have been seriously injured and are having trouble breathing, for example, it’s often necessary to administer drugs that sedate them and cause their muscles to relax so that emergency personnel can insert a breathing tube in the windpipe.

“All of a sudden you have a life-critical procedure and you’re using your second-best drug or a drug you’re less familiar with,” said Dr. Arjun Venkatesh, an assistant professor of emergency medicine at Yale School of Medicine and a study co-author.

Venkatesh said his own experience with recurring shortages of such basic but critical medicines as saline solution while working in the emergency department at Yale-New Haven Hospital was the impetus for the study.

Patients are naturally often unaware of drug shortages in the emergency department, and there’s no data to show that substituting a preferred drug with one that a doctor is less comfortable with results in patient harm, experts say.

“But if you extrapolate this problem over 140 million emergency department visits annually, I don’t see how patients couldn’t have been harmed by [substitutions],” said Dr. Frederick Blum, an associate professor of emergency medicine at West Virginia University School of Medicine who is a former president of the American College of Emergency Physicians.

The Food and Drug Administration Safety and Innovation Act of 2012 contains provisions aimed at stemming these problems, including requiring reporting of shortages by drug manufacturers to the FDA and expediting inspections and reviews by the FDA of alternative products and manufacturing facilities.

“We need more,” Venkatesh said. “At the national level, they need to provide more support around generic injectables and antibiotics, the two areas that are ripe for improvement.”

The FDA continues to work closely with manufacturers to resolve shortages, said agency spokesman Christopher Kelly.

“In the past couple of years, numbers of new shortages have gone down and that’s largely due to increased notifications by manufacturers,” Kelly said in a statement. Injectable drugs “are particularly susceptible to shortages and can be difficult to solve.”

Changing the economics of these drugs could help, said George Washington’s Pines, noting that profit margins are thin and there’s not a lot of extra capacity in the system if one manufacturer stops producing a drug. The Health Affairs study suggests tax credits, rebates or temporary market exclusivity as potential strategies to improve the supply of generic injectables, among other things.

David Gaugh, senior vice president for sciences and regulatory affairs at the Generic Pharmaceutical Association, said drugmakers’ efforts have helped decrease the shortages but acknowledged more is needed. He called for continued communication between regulators and generic drug manufacturers on the issues and improvements in the drug review process. “The only way to mitigate current shortages and prevent future shortages from occurring is a collaborative effort,” he said.

Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

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