The international journal of healthcare improvement 
BMJ Qual Saf 2012;21:709-712 doi:10.1136/bmjqs-2012-001368 Kaveh G Shojania, EditorCorrespondence to Dr Kaveh G Shojania, Sunnybrook Health Sciences Centre and University of Toronto Centre for Patient Safety, Room H468, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada; kaveh.shojania{at}utoronto.ca The concept of medical harm has existed since antiquity, famously discussed by Hippocrates and passed on in the term ‘iatrogenesis’, from the Greek for ‘originating from a physician’. The influential 9th century Arab physician, al-Ruhawi, wrote on this topic, and many others acknowledged the problem of medical harm over the centuries. In the 1860s, Oliver Wendell Holmes, Sr, a prominent American physician and popular writer, stated in an address to the Massachusetts Medical Society: “If the whole materia medica, as now used, could be sunk to the bottom of the sea, it would be all the better for mankind—and all the worse for the fishes”. This same decade also saw the first appearance of Florence Nightingale's work with William Farr on hospital mortality reports, drawing attention to the much higher mortality in London hospitals compared with rural ones.1
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OPEN ACCESS Helen Hogan1, Frances Healey2, Graham Neale3, Richard Thomson4, Charles Vincent3, Nick Black1 1Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK 2National Patient Safety Agency, London, UK 3Clinical Safety Research Unit, Imperial College, London, UK 4Institute of Health and Society, University of Newcastle, Newcastle upon Tyne, UK Correspondence to Dr Helen Hogan, Clinical Lecturer in UK Public Health, Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK; helen.hogan{at}lshtm.ac.uk Contributors RT was responsible for the original study idea. All authors contributed to the design of the study and the review forms. HH and GN were responsible for recruiting and training reviewers. HH was responsible for data collection and analysis and, with GN, provided additional support to reviewers. All authors contributed to data interpretation. HH and NB drafted the manuscript and all authors contributed to its revision. HH is guarantor. Accepted 21 May 2012 Published Online First 7 July 2012 Abstract Introduction Monitoring hospital mortality rates is widely recommended. However, the number of preventable deaths remains uncertain with estimates in England ranging from 840 to 40?000 per year, these being derived from studies that identified adverse events but not whether events contributed to death or shortened life expectancy of those affected. Methods Retrospective case record reviews of 1000 adults who died in 2009 in 10 acute hospitals in England were undertaken. Trained physician reviewers estimated life expectancy on admission, to identified problems in care contributing to death and judged if deaths were preventable taking into account patients' overall condition at that time. Results Reviewers judged 5.2% (95% CI 3.8% to 6.6%) of deaths as having a 50% or greater chance of being preventable. The principal problems associated with preventable deaths were poor clinical monitoring (31.3%; 95% CI 23.9 to 39.7), diagnostic errors (29.7%; 95% CI 22.5% to 38.1%), and inadequate drug or fluid management (21.1%; 95% CI 14.9 to 29.0). Extrapolating from these figures suggests there would have been 11?859 (95% CI 8712 to 14?983) adult preventable deaths in hospitals in England. Most preventable deaths (60%) occurred in elderly, frail patients with multiple comorbidities judged to have had less than 1 year of life left to live. Conclusions The incidence of preventable hospital deaths is much lower than previous estimates. The burden of harm from preventable problems in care is still substantial. A focus on deaths may not be the most efficient approach to identify opportunities for improvement given the low proportion of deaths due to problems with healthcare. Hospital mortality patient safety medical errors adverse events Footnotes Funding The funders of the study, the National Institute of Health Research, Research for Patient Benefit Programme had no role in study design, data collection, data analysis, data interpretation, or composition of the report. The corresponding author had full access to all data in the study and had final responsibility for the decision to submit for publication. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. Competing interests All authors have completed the unified competing interest form at http://www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare that neither authors nor their family relations have a financial or non-financial interest that might be relevant to the submitted work. Patient consent Patients in the study were deceased. Section 251 of the National Health Service Act 2006 for the use of patient identifiable information without consent was gained. Ethics approval Ethics approval was received from the National Hospital for Neurology and Neurosurgery and the Institute of Neurology joint multi-centre research ethics committee and research governance approval was granted by each participating Trust. Provenance and peer review Not commissioned; internally peer reviewed. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode. 
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