Medicine That Kills

Medicine That Kills
By Gary Null, Ph.D
Reposted with Permission at:
Institute for Health Research – http://www.InHeRe.org
Dr. Null’s Web Site: http://www.garynull.com/
May 31, 2016

“American science and public health is the finest in the world, with the smartest people working with the latest technologies to prevent and cure disease. We are exceptional.”

That is a common belief held by several million people working within the medical industrial complex. The problem is, it’s untrue. In fact, it’s just the opposite.  American medicine kills more people unnecessarily than any other national medical system in the industrialized world. As Harvard School of Medicine professor Lucian Leape noted, American medicine kills 3 jumbo jets-worth of patients every 48 hours.(1)

In this series we review the startling science which suggests that deaths from medical error in the US may be conservatively estimated at 400,000 annually, while severe injuries from medical error may top 10,000,000.(2,3)  This equates to 8 million deaths and 200,000,000 severe injuries due to modern medical medicine during the past twenty years. It is higher than the casualties from any single conflict or war in American history.

American citizens should be alarmed that no federal effort is being made to prevent or reverse this growing trend.  What does this reveal about the medical establishment today?  What does it tell us about the level of training and competency of numerous qualified physicians, nurses, dentists, nutritionists, hospitals and scientists?  And more so, what can be said about the integrity of pharmaceutical companies, the federal health agencies and their thousands of employees that keep the medical machine running? And then what about the roles of mainstream media, universities and professional institutions and foundations and the so-called medical experts who are supposed to represent the highest standards of scientific ethics? Finally, what can be said about the tens of millions of Americans who are complacent and buy into this all-pervading establishment?

In retrospect, the nation suffers from severe cognitive dissonance and lives in denial about health standards and disease. American medicine feeds upon corruption, greed, malfeasance and self-serving interests. However, many prominent, respected medical voices have identified these problems and spoken out against them. This group includes Harvard professor and former editor of the prestigious New England Journal of Medicine Dr. Marcia Angell, former FDA Associate Director for Science and Medicine Dr. David Graham and the CDC’s senior epidemiologist Dr. William Thompson.

For decades independent journalists have exposed the impropriety of the medical industrial complex. Here is a list of just some of the groundbreaking independent investigative reporting exposing the corruption of mainstream medicine:

These authors may be opinion leaders but they are not policymakers. Policymakers are so firmly in embedded into medicine’s controlled establishment that they are able to withstand the exposés and whistleblowers who bring their negligence and failures to public attention. Negative media, scandals, crimes of science don’t injure their careers nor their professional standings.

There are many hundreds of original in-depth investigative reports, including my own Death by Medicine, which required over 5 years of intensive research by five physicians and doctorates. I have released many award-winning documentaries such as Death by Medicine, War on Health, Prescription for Disaster, Silent Epidemic, Autism: Made in the USA and others. Yet what is the cumulative impact of all this investigative reporting upon current federal health policies and regulation? ZERO.

The US spends more money on domestic healthcare than any other country in the world. Grants and funding have been funnelled to millions of people, including over 900,000 physicians and nurses, hundreds of hospitals, pharmaceutical and medical technology companies, but the end-product is never thoroughly reviewed and assessed for viable success. Therefore, what incentive is provided to institute change if only medical failures are rewarded?

Has anyone ever heard of a physician or hospital refunding a patient’s care after medical error resulted in his or her death? And yet the public and media have the temerity to praise this medical paradigm’s leaders as heroes who are fighting the good fight against cancer, or AIDS or Alzheimer’s and diabetes, without ever questioning whether or not the entire paradigm might be flawed?

Unfortunately today’s medical establishment and its leaders won’t change. It’s too large to change.  There are too many vested interests and capitalizing on projected revenues is too entrenched into the system’s modus operandi. However, this doesn’t mean that we as individuals cannot change. Harvard Medical School’s Marcia Angell observed,

***

In January 2016 federal multidistrict litigation commenced against Pfizer over its hugely popular cholesterol-lowering drug, Lipitor. After a 2012 study found the statin drug increased type 2 diabetes risks by 50 percent among postmenopausal women, Pfizer stands accused of not providing adequate warning about Lipitor’s life-threatening adverse effects.(4)  Thousands of personal injury lawsuits have been filed across the country by patients alleging they were harmed by the drug.

Lipitor was launched in 1996 and is the most successful medication in pharmaceutical history with sales over $131 billion. Predictably, financial settlements from the lawsuits will amount to a pittance of the drug’s overall revenues.

Pfizer has knowingly put millions of patients’ health and lives at risk; nevertheless, following a settlement Pfizer’s business returned to normal.  Nothing fundamentally changed and the corporation’s revenues simply increased. Since the revelation of the diabetes link, the company has continued to earn billions on Lipitor sales and no one is being held accountable.  More egregious is that nobody in the mainstream media speaks about the numerous scandals that plague the medical-industrial complex and its consistent bottom line to prioritize profit over health.

There is a serious emergency when federal regulatory agencies continue to approve medications, drugs and vaccines with numerous harmful and sometimes lethal side effects. Increasingly the FDA and CDC act as their own critics. Neither is the government blind to its own deficiencies in healthcare delivery. The Institute of Medicine (IOM), a part of the United States National Academy of Sciences, states:

The IOM refers to “the nation’s epidemic of medical errors.” A large percent of these errors are related to adverse drug events (ADEs). An ADE is a broad term used to describe harm caused by medical intervention related to drugs, whereas an adverse drug reaction (ADR) involves injury caused by a medication prescribed at a normal dose. The FDA states that “ADRs are one of the leading causes of morbidity and mortality in healthcare.”(6) Dr. Curt Furburg published an article in the Archives of Internal Medicine proposing sweeping changes throughout the FDA.  Furburg and his colleagues write, “We see eight major problems with the current system of assessment and assurance of drug safety at the FDA.” A fundamental problem is the FDA’s initial review for drug approval that often fails to detect serious ADRs: “A study by the US General Accountability Office (GAO) concluded that 51% of all approved drugs had at least one serious ADR that was not recognized during the approval process.”(7)

Seeing the Bigger Picture

Until recently, public health researchers could cite only isolated statistics to make their case about the high risks of conventional medicine. No one had ever analyzed and compiled all the published literature dealing with injuries and deaths directly associated with federally protected medical practice.

Over a decade ago, several medical researchers and I spent years meticulously reviewing the statistical evidence regarding iatrogenic injury and death—that is, those conditions and deaths induced inadvertently by a physician or surgeon or by a medical treatment or diagnostic procedure. Our conclusions were shocking.

Our most stunning analysis was that the total number of deaths caused by conventional medicine is more than 700,000 per year, making the American medical system itself the leading cause of death and injury in the US. The statistics present a grim reality for the American patient. In contrast, the purported leading causes of death in the United States today, heart disease and cancer, are responsible for 611,105 and 584,881 annual deaths, respectively. (8)  But has there been any improvement in the last 10 years since our figures were revealed to the world? Hardly.

In 2013, John James, PhD. published an article in the Journal of Patient Safety examining the prevalence of iatrogenic death in America. James concluded that more than 400,000 patients die in hospitals each year due to preventable harm. (9) He also stated that “serious harm seems to be 10- to 20-fold more common than lethal harm.” (10) In other words, anywhere between 4 million and 8 million Americans are seriously harmed during hospital admissions annually.

In a recent 2016 report, co-authors Dr. Martin Makary and Dr. Michael Daniel at Johns Hopkins University School of Medicine estimated that over 250,000 deaths occur each year due to modern medicine’s errors. (11) However, the authors concede that the actual figure is far greater because their statistics only account for hospital deaths and not outpatient or nursing home settings. During an interview, Dr. Makary pointed out that death certificates do not reflect medical error. (12) He went on to state that “Incidence rates for deaths directly attributable to medical care gone awry haven’t been recognized in any standardized method for collecting national statistics… The medical coding system was designed to maximize billing for physician services, not to collect national health statistics, as it is currently being used.” (13)

Since population studies on iatrogenic deaths are sorely inadequate, it is reasonable to project an accurate mortality rate that surpasses the 797,926 figure we arrived at over a decade ago. In addition, a 2010 study showed that the frequency of ADEs (fatal and otherwise) has steadily trended upwards over the past years.(14) Nor does research into medical errors in nursing homes reflect improvement in patient safety. A 2009 study found serious discrepancies in the administration of medications for nearly 3 out of 4 admissions in nursing facilities. (15) In another study that evaluated assisted living facilities in South Carolina, healthcare staff committed errors in the preparation and administration of medication over 40% of the time. (16)

Given these astounding figures, it’s only right to ask how is it possible that our regulatory agencies have failed to address our costly nationwide epidemic of medical errors. To begin our search for answers we will turn our attention to the FDA, its astonishingly shoddy science and disturbing corruption that plagues America’s leading federal health agency.

Blowing the Whistle on Bad Medicine: Dr. David Graham

We decided to publish this information to call attention to the failure of the American medical system. By exposing the gruesome statistics, a basis may be established that might encourage competent and compassionate medical professionals to recognize the inadequacies of today’s medical establishment and begin to institute progressive reforms. One such professional is Dr. David Graham, whose testimony before Congress provides an important context for our discussion.

On November 18, 2004, Dr. David Graham, a former Associate Director for Science and Medicine in the FDA’s Office of Drug Safety, testified before the US Senate. Dr. Graham graduated from the Johns Hopkins University School of Medicine, and trained in Internal Medicine at Yale and in adult Neurology at the University of Pennsylvania. (17)  His education and extensive experience qualify his expert opinion on the failures of pharmaceutical drugs.

Dr. Graham told the Senate:

Testifying about Merck’s Vioxx®, Dr. Graham states:

According to Dr. Graham. “Not only did the FDA ignore known risks from Vioxx® and related drugs but . . . it tried to prevent Graham and others from publicizing their own research that proved the extent of these risks.”(21)

Graham’s concerns were echoed by some members of Congress who heard his testimony. Committee Chairman Charles E. Grassley (R–Iowa) said he was concerned that the FDA “has a relationship with drug companies that is too cozy.”(22)  Sen. Jeff Bingaman (D–New Mexico) said the problem was within the FDA’s own culture.“ This culture has been described as one whereby the pharmaceutical industry, which the FDA is mandated to regulate, is seen by the FDA as its client instead.(23)

In Graham’s view, drug safety problems began in 1992 with the passage of a law aimed at getting lifesaving drugs onto the market faster. In order to increase the FDA approval process, the law forced pharmaceutical companies to pay for most of the review process’ costs.  That left the FDA “captured by industry,” says Graham. “He who pays the piper calls the tune.” (24)

The American Society of Health-System Pharmacists reports that Graham testified “in February [2007] that, had it not been for the protection of Sen. Charles Grassley (R–Iowa), FDA would have fired him for publicly speaking out about his concerns about Vioxx® and other drugs.” (25)

Dr. Graham says, “ You need to weed the garden patch of drugs that aren’t doing what they’re supposed to do. The FDA has not been very good about that; it likes to cultivate all these weeds.”(26)  Dr. Graham “named five other drugs whose safety is suspect, and noted that ‘the FDA as currently configured is incapable of protecting America against another Vioxx®.’” (27) Many media sources present at the hearing, such as the Los Angeles Times and Medscape Medical News, (28) report that Graham then added, “ We are virtually defenseless,”(29)  but this sentence does not appear in the final transcript and may have been stricken from the record.

One report begins, “The American public is ‘virtually defenseless’ if another medication such as Vioxx® proves to be unsafe after it is approved for sale, a government drug safety reviewer told a congressional committee.”(30)

Medicine Today: As Dangerous as Ever

A decade has passed since Dr. Graham’s public statements exposing the dangerous bad science and corruption and that infests the FDA. It’s difficult to imagine that such public exposure hasn’t forced the agency to clean up its act, but the evidence clearly shows that our government health officials would rather support pharmaceutical profiteering than the health and safety and American citizens.

The FDA’s questionable operations were put under the spotlight in a 2015 article appearing in JAMA Internal Medicine titled “ Research Misconduct Identified by the US Food and Drug Administration Out of Sight, Out of Mind, Out of the Peer-Reviewed Literature,.” The article is a sobering assessment of the scale of scientific fraud and deception carried out by the FDA. Author Charles Seife of New York University examined the nature of the FDA’s inspection of various drug trials on human participants between 1998 and 2013.

The investigation’s results were stunning:

Fifty-seven published clinical trials were identified for which an FDA inspection of a trial site had found significant evidence of 1 or more of the following problems: falsification or submission of false information, 22 trials (39%); problems with adverse events reporting, 14 trials (25%); protocol violations, 42 trials (74%); inadequate or inaccurate recordkeeping, 35 trials (61%); failure to protect the safety of patients and/or issues with oversight or informed consent, 30 trials (53%); and violations not otherwise categorized, 20 trials (35%). Only 3 of the 78 publications (4%) that resulted from trials in which the FDA found significant violations mentioned the objectionable conditions or practices found during the inspection. No corrections, retractions, expressions of concern, or other comments acknowledging the key issues identified by the inspection were subsequently published. (31)

These disturbing data suggest that the FDA’s evaluation of pharmaceuticals for safety and efficacy may be so flawed that only 4% of all trial results are identified as such. As a result, FDA scientists and officials responsible for approving drugs to the market are kept largely uninformed about the egregious scientific misconduct involved in obtaining study data. Further, these erroneous and fraudulent studies are published in peer-reviewed scientific literature and accepted as valid science

Seife commented on the FDA’s staggering scientific impropriety in an article he composed for Slate:

RECORD 4 was one of four large clinical trials that involved thousands of patients who were recruited at scores of clinical sites in more than a dozen countries around the world. The trial was used as evidence that a new anti-blood-clotting agent, rivaroxaban, was safe and effective. The FDA inspected or had access to external audits of 16 of the RECORD 4 sites. The trial was a fiasco. At Dr. Craig Loucks’ site in Colorado, the FDA found falsified data. At Dr. Ricardo Esquivel’s site in Mexico, there was “systematic discarding of medical records” that made it impossible to tell whether the study drug was given to the patients. At half of the sites that drew FDA scrutiny—eight out of 16—there was misconduct, fraud, fishy behavior, or other practices so objectionable that the data had to be thrown out. The problems were so bad and so widespread that, contrary to its usual practice, the FDA declared the entire study to be “unreliable.” Yet if you look in the medical journals, the results from RECORD 4 sit quietly in The Lancet without any hint in the literature about falsification, misconduct, or chaos behind the scenes. This means that physicians around the world are basing life-and-death medical decisions on a study that the FDA knows is simply not credible. (32)

***

How are we supposed to have faith in a medical establishment that is responsible for the injury and death of thousands of Americans daily? How else does modern medicine exploit illness for profit and what lies at the root of this corrupt system? In the next article, we will uncover more about modern medicine’s deadly repercussions in the lives of millions of American people.

Endnotes:

Gary Null’s web site: http://www.garynull.com/

1.     Leape, L. L. 1994. Error in medicine. JAMA, 272 (23):1851–7.

2.     James, John T. “A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care.” Journal of Patient Safety 9, no. 3 (September 9, 2013): 122-28. Accessed May 9, 2016. doi:10.1097/pts.0b013e3182948a69.

3.     Cha, Ariana Eunjung. “Researchers: Medical Errors Now Third Leading Cause of Death in United States.” Washington Post. May 3, 2016. Accessed May 11, 2016. https://www.washingtonpost.com/news/to-your-health/wp/2016/05/03/researchers-medical-errors-now-third-leading-cause-of-death-in-united-states/.

4.     Culver AL, Ockene IS, Balasubramanian R, et al. Statin Use and Risk of Diabetes Mellitus in Postmenopausal Women in the Women’s Health Initiative. Arch Intern Med. 2012;172(2):144-152. doi:10.1001/archinternmed.2011.625.

5.     Institute of Medicine, US National Academy of Sciences. November 1999. To Err Is Human: Building a Safer Health System. http://www.iom. edu/Object.File/Master/4/117/ToErr-8pager. pdf (accessed January 25, 2009).

6.     Center for Drug Evaluation and Research. U.S. Food and Drug Administration. Preventable Adverse Drug Reactions: A Focus on Drug Interactions. Last updated July 31, 2002. http:// www.fda.gov/cder/drug/drugReactions/default. htm#ADRs:%20Prevalence%20and%20Inci- dence (accessed January 25, 2009).

7.     Furberg, C. D., A. A. Levin, P. A. Gross, R. S. Shapiro, and B. L. Strom. 2006. The FDA and drug safety: a proposal for sweeping changes. Arch Intern Med 166 (18):1938–42.

8.     Nichols, Hannah. “Public Health Heart Disease Cancer / Oncology Stroke The Top 10 Leading Causes of Death in the US.” Medical News Today. September 21, 2015. Accessed April 21, 2016. http://www.medicalnewstoday.com/articles/282929.php.

9.     James, John T. “A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care.” Journal of Patient Safety 9, no. 3 (September 9, 2013): 122-28. Accessed May 9, 2016. doi:10.1097/pts.0b013e3182948a69.

10.   Ibid

11.   Makary MA, Daniel M. BMJ. 2016 May 3;353:i2139. doi: 10.1136/bmj.i2139.

12.   Johns Hopkins Medicine. “Medical errors now third leading cause of death in United States.” ScienceDaily. ScienceDaily, 4 May 2016. www.sciencedaily.com/releases/2016/05/160504085309.htm.

13.   Ibid

14.   Bourgeois, Florence T., Michael W. Shannon, Clarissa Valim, and Kenneth D. Mandl. “Adverse Drug Events in the Outpatient Setting: An 11-year National Analysis.” Pharmacoepidemiology and Drug Safety Pharmacoepidem. Drug Safe. 19, no. 9 (September 19, 2010): 901-10. doi:10.1002/pds.1984.

15.   Tjia, J., Bonner, A., Briesacher, B. A., McGee, S., Terrill, E., & Miller, K. (2009). Medication Discrepancies upon Hospital to Skilled Nursing Facility Transitions. Journal of General Internal Medicine, 24(5), 630–635. http://doi.org/10.1007/s11606-009-0948-2

16.   Zimmerman S ; Love K ; Sloane PD; et al. Medication administration errors in assisted living: scope, characteristics, and the importance of staff training. J Am Geriatr Soc. 2011; 59: 1060-1068

17.   US Senate Finance Committee. Testimony of David J. Graham, MD, MPH, November 18, 2004. http://finance.senate.gov/hearings/ testimony/2004test/111804dgtest.pdf (accessed January 30, 2009).

18.   Ibid

19.   Alonso-Zaldivar, R., FDA Called ‘Defenseless’ Against Unsafe Drugs, Los Angeles Times, November 18, 2004. http://www.mcall.com/topic/ la-111804vioxx_lat,0,7473253.story (accessed January 31, 2009).

20.   US Senate Finance Committee. Testimony of David J. Graham, MD, MPH, November 18, 2004. http://finance.senate.gov/hearings/ testimony/2004test/111804dgtest.pdf (accessed January 30, 2009).

21.   National Coalition Against Censorship. FDA Suppressed Vioxx Studies Despite Evidence of Seri- ous Health Risks, November 25, 2004. http:// www.ncac.org/FDA_Suppressed_Vioxx_Studies (accessed January 30, 2009).

22.   Alonso-Zaldivar, R., “FDA Called ‘Defense- less’ Against Unsafe Drugs,” Los Angeles Times, November 18, 2004. http://www.mcall.com/ topic/la-111804vioxx_lat,0,7473253.story (accessed January 31, 2009).

23.   Ibid

24.   Yale Medicine. FDA’s top safety critic keeps a watchful eye on the public good, Summer 2005. References • 169 170 •Gary Null, PhD, et al. http://yalemedicine.yale.edu/ym_su05/faces. html (accessed January 31, 2009).

25.   Young, D., Safety Experts Call for Accountability from FDA, Drug Firms. American Society of Health-System Pharmacists, March 23, 2007. http://www.ashp.org/import/News/HealthSys- temPharmacyNews/newsarticle.aspx?id=2503 (accessed January 31, 2009).

26.    Loudon, Manette, interviewer. The FDA Exposed: An Interview With Dr. David Graham, the Vioxx Whistleblower, parts of this interview appear in Gary Null’s documentary film, Pre- scription for Disaster, Garynull.com, August 30, 2005, reprinted by Natural News. http://www. naturalnews.com/011401.html (accessed Janu- ary 31, 2009).

27.   US Senate Finance Committee. Testimony of David J. Graham, MD, MPH, November 18, 2004. http://finance.senate.gov/hearings/ testimony/2004test/111804dgtest.pdf (accessed January 30, 2009).

28.    Yale Medicine. FDA’s top safety critic keeps a watchful eye on the public good, Summer 2005. http://yalemedicine.yale.edu/ym_su05/faces. html (accessed January 31, 2009).

29.   Alonso-Zaldivar, R., FDA Called ‘Defense- less’ Against Unsafe Drugs, Los Angeles Times, November 18, 2004. http://www.mcall.com/ topic/la-111804vioxx_lat,0,7473253.story (accessed January 31, 2009).

30.   Kelly, J. Harsh criticism lobbed at FDA in Senate Vioxx hearing, Medscape Medical News, November 23, 2004. http://medgenmed.medscape. com/viewarticle/538021_print (accessed January 31, 2009).

31.   Seife C. Research Misconduct Identified by the US Food and Drug Administration: Out of Sight, Out of Mind, Out of the Peer-Reviewed Literature. JAMA Intern Med. 2015;175(4):567-577. doi:10.1001/jamainternmed.2014.7774.

32.   Seife, Charles. “The Food and Drug Administration Covers Up Evidence of Fraud, Fabrication, and Scientific Misconduct.” Slate Magazine. February 09, 2015. Accessed April 22, 2016. http://www.slate.com/articles/health_and_science/science/2015/02/fda_inspections_fraud_fabrication_and_scientific_misconduct_are_hidden_from.html.

Supplemental Statistics on Iatrogenic Death in the United States excerpted from Death By Medicine

As shown in Table 1, the estimated total number of iatrogenic deaths—that is, deaths induced inadvertently by a physician or surgeon or by medical treatment or diagnostic procedures—in the US annually is at least 581,926. It is evident that the American medical system is itself the leading cause of death and injury in the US. By comparison, approximately 652,091 Americans died of heart disease in 2005, while 559,312 died of cancer.(45) The mortality costs alone exceed $215 billion a year. “Healthcare costs in the United States are growing at an unsustainable rate,” according to former Senator Ron Wyden, who serves on the Senate’s Finance Committee, Subcommittee on Healthcare.(46

The National Coalition on Healthcare reports that annual healthcare spending in the US has been increasing two to five times the rate of inflation since 2000.(47) In 2006, Americans spent more than $2.2 trillion on healthcare.(48) Total healthcare spending was $2.4 trillion in both 2007 and 2008, or $7,900 per person, which represented 17 percent of the gross domestic product (GDP).(70) That’s about 4.3 times the amount spent on national defense.(71) The total was projected to reach $3.1 trillion in 2012.(72) The National Coalition on Healthcare further states:It is estimated that we have spent as a nation nearly 16 trillion dollars on healthcare since 2000, but this expenditure has not resulted in demonstrably better quality of care or better patient satisfaction compared to other nations.(73)

Jason Lazarou, MSc, estimated 106,000 annual drug errors in his groundbreaking 1998 report in the Journal of the American Medical Association(74) the Institute of Medicine esti-

mated 98,000 annual medical errors. But if we use Dr. Lucian L. Leape’s 1997 medical and drug error rate of 3 million(75) multiplied by the 14% fatality rate he used in 1994,76 we find that the number of deaths would be increased by 216,000, for a total of 797,926 deaths annually as shown in Table 2.

49. Lazarou, J., B. H. Pomeranz, and P. N. Corey. 1998. Incidence of adverse drug reactions in hospitalized patients: a meta- analysis of prospective studies. JAMA 279 (15):1200–5.

50. Suh, D. C., B. S. Woodall, S. K. Shin, and E. R. Hermes-De Santis. 2000. Clinical and economic impact of adverse drug reactions in hospitalized patients. Ann Pharmacother 34 (12):1373–9.

51. Center for Drug Evaluation and Research. U.S. Food and Drug Administration. Preventable Adverse Drug Reactions: A Focus on Drug Inter-

actions. Last updated July 31, 2002. http:// www.fda.gov/cder/drug/drugReactions/default. htm#ADRs:%20Prevalence%20and%20Inci- dence (accessed January 25, 2009).

52. Institute of Medicine, US National Academy of Sciences. November 1999. To Err Is Human: Building a Safer Health System. http://www.iom. edu/Object.File/Master/4/117/ToErr8pager. pdf (accessed January 25, 2009).

53. Thomas,E.J.,D.M.Studdert,H.R.Burstin,E. J. Orav, T. Zeena, E. J. Williams, K. M. Howard, P. C. Weiler, and T. A. Brennan. 2000. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care 38 (3):261–71.

54. Thomas, E. J., D. M. Studdert, J. P. Newhouse, B. I. Zbar, K. M. Howard, E. J. Williams, and T. A. Brennan. 1999. Costs of medical injuries in Utah and Colorado. Inquiry 36 (3):255–64.

55. Xakellis, G. C., R. Frantz, and A. Lewis. 1995. Cost of pressure ulcer prevention in long-term care. J Am Geriatr Soc 43 (5):496–501.

56. Barczak, C. A., R. I. Barnett, E. J. Childs, and L. M. Bosley. 1997. Fourth national pressure ulcer prevalence survey. Adv Wound Care 10 (4):18–26.

57 Health Grades Quality Study, Patient Safety in American Hospitals, July 2004. http:// www.healthgrades.com/media/english/pdf/ hg_patient_safety_study_final.pdf (accessed March 3, 2009).

58. Centers for Disease Control and Prevention. Estimates of Healthcare-Associated Infections, last modified May 30, 2007. http://www.cdc. gov/ncidod/dhqp/hai.html (accessed January 24, 2009).

59. Weinstein, R. A. 1998. Nosocomial infection update. Emerg Infect Dis 4 (3):416–20.

60. Fourth Decennial International Conference on Nosocomial and Healthcare-Associated Infections. Morbidity and Mortality Weekly Report. February 25, 2000, Vol. 49, No. 7, p. 138.

61. Starfield, B. 2000. Is US health really the best in the world? JAMA 284 (4):483–5.

62. Nursing Home Residents Dying of Hunger, Thirst. Consumer Affairs, November 29, 2004. http://www.consumeraffairs.com/news04/ nursing_home_neglect.html (accessed March 4, 2009).

63. Starfield, B. 2000. Deficiencies in US medical care. JAMA 284 (17):2184–5.

64. Weingart, S. N., L. Wilson R. Mc, R. W. Gibberd, and B. Harrison. 2000. Epidemiology of medical error. West J Med 172 (6):390–3.

65. Siu, A. L., W. G. Manning, and B. Benjamin. 1990. Patient, provider and hospital characteristics associated with inappropriate hospitalization. Am J Public Health 80 (10):1253–6.

66. Thomas, E. J., D. M. Studdert, J. P. Newhouse, B. I. Zbar, K. M. Howard, E. J. Williams, and T. A. Brennan. 1999. Costs of medical injuries in Utah and Colorado. Inquiry 36 (3):255–64.

67. Available at: http://www.ahrq.gov/news/ ress/ pr2003/injurypr.htm. (Accessed May 22, 2006).

68. Leape LL.Unnecessary surgery.Health Serv Res. 1989 Aug; 24(3):351–407.

69. NationalCoalitiononHealthCare.HealthInsur- ance Costs: Facts on the Cost of Health Insurance and Health Care, NCHC, 2009. http:// www.nchc.org/facts/cost.shtml (accessed Jan- uary 28, 2009).

70. NationalCoalitiononHealthCare.“DidYouKnow?” section of home page of NCHC, 2009. http://www. nchc.org/ (accessed January 27, 2009).

71. National Coalition on Health Care. Health Insurance Costs: Facts on the Cost of Health Insurance and Health Care, NCHC, 2009. http://www.nchc. org/facts/cost.shtml (accessed January 28, 2009).

72. NationalCoalitiononHealthCare.“DidYouKnow?” section of home page of NCHC, 2009. http://www. nchc.org/ (accessed January 27, 2009).

73. Lazarou, J., B. H. Pomeranz, and P. N. Corey. 1998. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. JAMA 279 (15):1200–5.

74. National Patient Safety Foundation. Nationwide poll on patient safety: 100 million Americans see medical mistakes directly touching them [press release]. McLean, VA: October 9, 1997.

75. Leape, L. L. 1994. Error in medicine. JAMA 272 (23):1851–7.

76. National Patient Safety Foundation. Nationwide poll on patient safety: 100 million Americans see medical mistakes directly touching them [press release]. McLean, VA: October 9, 1997.

77. Ibid.

78. Xakellis, G. C., R. Frantz, and A. Lewis. 1995. Cost of pressure ulcer prevention in long-term care. J Am Geriatr Soc 43 (5):496–501.

79. Barczak, C. A., R. I. Barnett, E. J. Childs, and L. M. Bosley. 1997. Fourth national pressure ulcer prevalence survey. Adv Wound Care 10 (4):18–26.

80. Centers for Disease Control and Prevention. Estimates of Healthcare-Associated Infections, last modified May 30, 2007. http://www.cdc. gov/ncidod/dhqp/hai.html (accessed January 24, 2009).

81. Health Grades Quality Study, Patient Safety in American Hospitals, July 2004. http://www. healthgrades.com/media/english/pdf/hg_ patient_safety_study_final.pdf (accessed March 3, 2009).

82. Weinstein, R. A. 1998. Nosocomial infection update. Emerg Infect Dis 4 (3):416–20.

83. Fourth Decennial International Conference on Nosocomial and Healthcare-Associated Infections. Morbidity and Mortality Weekly Report. February 25, 2000, Vol. 49, No. 7, p. 138.

84. Available at: http://www.cmwf.org/programs/ elders/burger_mal_386.asp. (accessed May 22, 2006).

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