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Public Health Errors

Costing Lives, Millions at a Time

Holtgrave, David R. PhD

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Journal of Public Health Management and Practice: May 2010 - Volume 16 - Issue 3 - p 211-215
doi: 10.1097/PHH.0b013e3181bee698
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In Brief

Since 2000, there has been an explosive growth in the literature focused on the identification, reporting, cost, and prevention of medical errors.1–4 As shown in Table 1, there are now thousands of papers focused on medical (or clinical) errors (or mistakes), what causes them, and how they can be reduced in the future. It is believed that in the United States, tens of thousands of people die each year because of medical errors, and the costs of these errors to society may approximate $29 billion per year.1–4

Number of entries in the literatures on medical, clinical, and public health errors: Results of a August 29, 2009, PubMed Searcha

This focus and attention on medical errors is entirely appropriate and necessary. We find it remarkable that the analogous topic of public health errors has received far less attention in the literature. Given that public health systems target large groups, from hundreds to millions of people at a time, errors in such systems have the potential for catastrophic consequences. Table 1 shows that as of August 29, 2009, a search in PubMed found no articles identified through using the search terms, public health errors, public health mistakes, or public health omissions. Only 2 papers were identified when using the search term policy mistake.5,6 Additional searches in Google Scholar and Google Web identified no additional publications and uncovered only a small number of instances where the phrase “public health errors” (or “mistakes” or “omissions”) was used in a presentation or a speech. As far as I could discern, there exists scant attention to this topic as the focus of any particular document or project. Perhaps, the closest document is the transcript of a 2003 speech by Dr William Foege to the Association of State and Territorial Health Officials in which he notes that public health omissions—by which he meant the failure to deliver or scale up an evidence-based program in public health—are an area of critical concern for public health.7

Of note, a Google Web search identified approximately 143 000 hits for the term public health failure. While the term public health failure was used in these instances to include a broad range of circumstances—from radon exposure to population increases in obesity—it is noteworthy that little attention has been devoted to defining the term or categorizing the types of or failures that might exist. Similarly, the term public health malpractice yields 74 300 hits in a Google Web search. The term is often used in regard to the debate over whether and how to best maintain folic acid as a food-supply supplement and in discussions regarding the need to control tobacco use and obesity. It has also been used in discussions of flat funding for human immunodeficiency virus (HIV) prevention. To the best of our knowledge, the discussions of public health malpractice do not appear to definitively systematize or distinguish among instances of “malpractice” (though some attempt is made to legally describe a public health duty to act).8

Overview of Commentary

I am unable to locate through in-depth literature searches (a) a formal definition of the term public health error, (b) any estimate of the prevalence of these errors, (c) any estimate of the number of people who die or who are harmed each year by public health errors, or (d) any formal, systematic recommendations as to how to prevent public health errors. In this brief commentary, I simply wish to call attention to the lack of examination of the topic of “public health errors” in the literature, provide a few illustrations of “public health errors,” offer a possible definition of the term, and, most importantly, encourage more research and further conceptualization of an area in need of further discourse and study.

Possible Illustrations of Public Health Errors

There are at least 3 general types of situations that could potentially be considered as public health errors:

  1. Errors of deliberate commission. These are acts that are clearly contrary to existing standards, evidence, practices, laws, or ethical norms, and that occur when other courses of action are available. These are public health errors in a setting where an existing standard of public health practice exists (eg, from the Centers for Disease Control and Prevention, the World Health Organization, or a state public health law), the actor has acted in a manner contrary to such standards and generally is culpable for his or her action. Examples might be the divulging of names of persons living with HIV from a confidential surveillance dataset or providing a tuberculosis treatment regimen that is known to be substandard. Such acts are characterized by a person or group of persons acting with knowledge to do something that is clearly a violation of public health laws or standards. There seems to be little question that such acts should be called “public health errors.” I believe and hope that such planful events of harm are few and far between in public health, but I know of no prevalence data on this point.
  2. Errors of willful omission. These are acts in which some person(s) know that a particular action is warranted to improve the public's health, but they consciously decide not to engage in that act. This is most consistent with the concepts Dr Foege discussed in 2003.7 A key example is not acting at all (or at the scale necessary) to contain a known and recognized public health threat. For instance, the ban on the use of federal funds for evidence–based needle and syringe exchange programs to prevent HIV infection and provide referrals for drug treatment is a glaring illustration of such a willful omission.9 Another illustration would be the failure of public health practitioners to control exposure to tobacco smoke in public places when it is well known that exposure to such smoke is harmful to persons passing through those public venues.
  3. The scant material on the Internet that discusses public health errors suggests two additional types of willful omission errors, and I include them here for the sake of comprehensiveness. One subtle example of an omission is the failure to build or utilize information systems known to be potentially helpful for guiding or assessing public health activities (eg, not conducting HIV-related sexual risk behavior national surveys, when it is known that such information is needed to guide and evaluate HIV and sexually transmitted disease prevention efforts).10 Another illustration is narrowly focusing on a medical aspect of a public health challenge, but ignoring the other “systems” or societal aspects of that challenge (eg, reducing all of HIV prevention to a simple matter of antibody screening only and entirely ignoring behavioral interventions already demonstrated to be effective).11,12 Willful omissions such as those described in this section have not traditionally or typically been called “public health errors,” but they could easily qualify as such.
  4. Errors of complacency. These errors might be ones of commission or omission but are more a function of inertia than of a clear choice. One example might be the Centers for Disease Control and Prevention paying insufficient attention to the growing hepatitis C problem in the United States (as manifested by allowing hepatitis programs to languish at their current, very low level of intensity).13 Another example is failing to keep up with relevant literature and missing important developments that could influence public health practice (eg, a health educator charged with cardiovascular health in a school system may miss important developments on best practices and thereby underperform in the quality of service delivery for the students). An additional example is a city health department failing to cite landlords who do not abate known high levels of lead in their rental properties. Instances of carelessness and complacency would seem to qualify as “errors” if the public health actors involved had the resources and knowledge to have known that they should have paid attention to a particular set of public health issues.

Bad Outcomes Might Not Be “Errors,” Strictly Speaking

The three categories of illustrations mentioned earlier would appear to qualify as “public health errors.” A common feature in those three categories of errors is an intent to do harm, or at least the lack of caring about fully discharging one's public health duty to serve the public good. However, there are other instances of poor outcomes of public health actions that might not be considered “errors” as much as unfortunate circumstances or choices.

For instance, we might consider the human limits of judgment and cognition.14 These may be less a type of “error” and better considered a human “limitation.” For example, imagine that there is a major avian flu outbreak in the United States. Well-intended and informed public health officials may do their very best in containing the outbreak, treating the sick, and preventing further infection. However, the information coming in about the outbreak is so fast-paced and complex that human cognition cannot process it all effectively. Furthermore, there may be few or no cases of exactly analogous prior learnings upon which to base these public health decisions (ie, no relevant mental models exist for the situation at hand) and in the end many of the decisions in such cases may be one-off judgment calls. While public health decision makers acting in such circumstance could productively benefit from the development and use of decision support systems and aids,15 it seems that we are not talking about issues of carelessness, lack of will, or bad intent, but more about matters of human cognitive ability or capacity. In a recent book about scientific controversies and errors in the HIV epidemic, Holmberg16 illustrates a number of statistical reasoning errors that he believes impacted the course of HIV/AIDS in the United States.

There are also circumstances in which there is a legitimate but debatable prioritization of programs. As with the illustrations just above, this is not necessarily a type of error, but an instance of reasonable, caring people holding similar core values, yet, simply disagreeing on the best approach to achieve key public health goals. For instance, a group of decision makers in the federal public health funding process may all agree that they want to save the most lives, maximize the quality of life, and promote health equity within the confines of available resources. However, some of the decision makers might conduct a careful analysis that suggests that they should invest more heavily in one disease area, while another group of decision makers does an analysis and believes that they should invest more heavily in a different disease area. Let us assume for the moment that these differences of direction are truly based on public health data points, analyses, and interpretations, and are not driven by political goals; then it would seem that neither group of decision makers is committing an error as such (even though their choices may have suboptimal public health outcomes). Again, the development of decision-aiding tools and support systems may be of relevance here, but it is not a matter of malevolence or lack of caring at play. Also, sometimes differences of opinion on program prioritization may be a function of varying value systems among well-intentioned policy makers. For instance, some may believe that quarantine is always a violation of individual rights, but others may believe that quarantine is defensible when the overall public health is truly at stake and no other less-intrusive measure is available. It would appear that such a debate over the acceptable uses of quarantine powers is not so much a public health error as it is a true difference of value systems that must be made clear and transparent.

Sometimes, a public health actor acts with the best of intentions, utilizes all available information, consults key advisors and stakeholders, and makes a careful choice of action, but the outcome just turns out badly. This is not a public health error, but rather is an unfortunate stochastic event. For instance, a health commissioner may implement an evidence-based HIV-prevention street outreach program, only to find out after the fact that there was a manufacturing flaw in the condoms distributed. If the health department acts swiftly to rectify this problem, it could hardly be labeled an “error,” even though the consequences are severe and regrettable.

Furthermore, there may be other cases in which the public health actor is well intentioned but the necessary resources—broadly defined—are not available to that public health professional. The most obvious resource needed for a favorable public health outcome is usually financial. But human, temporal, and informational resources are also needed. If public health decision makers do not have such resources at hand, they might act with the best of intentions but still fail to achieve a good public health goal. However, those controlling the resources available to such a public health actor might be committing a public health error depending on their intent. For instance, a city health director might know that lead abatement is a priority to protect child health, and endeavors to start a new lead abatement program in the city. However, despite best efforts and intentions and initial small-scale successes, those who control the resources available to this health director willfully and knowingly withhold necessary funding to implement a good lead surveillance system across the city, and they also withhold the funding needed to abate lead wherever it is found (even though the city has a surplus funds account available). In such a case, we may have a public health error at the level of the appropriators of resources, but the city health director might be simply doing the very best with the resources available and not committing an “error” as such. This simplified example illustrates how the consideration of public health errors can become rapidly complex, given that there are multiple decision makers at play on multiple levels in many public health decisions.

Errors of Practice? Errors of Policy?

The identification of a party responsible for a medical error is complex but relatively clearer than it is in public health. If a surgeon leaves a scalpel in the body of a patient during a procedure or a hospital staff member fails to change the wound dressing of a hospital inpatient, we know who is responsible. In public health, it is also clear who committed an error if a public health practitioner commits some egregious acts such as publicly divulging the names of the patients in a cancer registry.

However, there are many actors involved in public health decision making, and this raises the question of whether there can be attributable “errors” of public health policy making as well as of public health practice. I argue that policy makers can indeed commit “errors” and should be held accountable for said errors if the policy makers know that the action they are taking is demonstrably harmful (relative to another policy option) and they have the financial, legal, and human resources to avoid implementing the relatively harmful policy. I recognize that this may be a controversial view; it argues that public sector policy makers should have clear accountability when they make choices to implement policy options that harm the public health. I also recognize that such a view may be unwieldy in terms of practicality; who will decide and how will they decide that a particular public health policy maker took a relatively harmful path with full knowledge and resources? These are open questions. Also worthy of further discussion is whether or not an action should be considered a public health error if the actor did not know the relevant data or fully understand the consequences of this action; whether the adage “ignorance is no excuse” is applicable in the discussion of public health errors merits attention.

Toward a Definition of Public Health Errors

Considering the illustrative areas above, I would submit that a possible definition of a public health error is as follows: “A public health error occurs when one or more stakeholders in a public health system commit a cognizant, negligent act of commission or omission that fails to achieve necessary public health outcomes.” This definition is analogous to the definition of an error offered by the Institute of Medicine:

The failure of a planned action to be completed as intended (error of execution) or the use of a wrong plan to achieve an aim (error of planning). An error may be an act of commission or an act of omission3(p4)

The Institute of Medicine, however, then goes on to define an adverse drug event as follows: “Any injury due to medicine (Bates et al., 1995b). Examples include a wrong dosage leading to injury (eg, rash, confusion, or loss of function) or an allergic reaction occurring in a patient not known to be allergic to a given medication.”3(p4)

Similarly, we pair our proposed definition of a public health error with the definition of the term adverse public health event: “A public health outcome in which a person or group of persons is either directly harmed by a public health action, or inadequately protected from an avoidable public health harm by the public health system.”

By using two terms, public health error and adverse public health event, we allow for the possibility that errors may be consequential or inconsequential (one may make an error that does or does not lead to an adverse event). Furthermore, we recognize that bad public health outcomes may be caused intentionally or unintentionally. This is consistent with the decision-analytic literature that distinguishes “good decisions” from “good outcomes.”17,18

Why the Study of Public Health Errors Is Important, and Conclusions

There are multiple reasons why we should study and address the topic of public health errors. First, such errors can clearly cost many lives. Every life that is lost while someone sits on a substance abuse treatment waiting list is a life lost because of a public health error. Second, without concerted study and attention, public health errors may simply go unidentified and thereby unaddressed. As noted above, in the public health arena, the decision makers are often less clearly identifiable, more distal, and more numerous than in clinical medicine (furthermore, the standards of performance are also more ambiguous). To increase accountability, decrease public health errors, and lower public health adverse events, we need a more direct identification, tracking, and discussion of the concept of public health errors.

Third, we need to distinguish levels and types of errors, failures to act, and legitimate alternative views and priority settings as we consider which situations demand reprimand and “fixing” versus those that simply constitute differing views on appropriate action. That everyone does not agree with a chosen public health strategy does not make the strategy an error by definition; however, implementing a strategy for which there may be considerable support can still be considered an error if there are overwhelming data to suggest that the policy would have significantly increased morbidity or mortality, particularly at a cost equivalent to that of other perhaps less effective programs that were implemented. While it might be of some utility to label some action or inaction a “public health failure” or an instance of “public health malpractice,” it is the systematic study of why such events occur that will enable the field to identify available levers of public health action.

Furthermore, it is problematic if a public health response to a challenge systematically ignores subclasses of the population, for example, disproportionately neglects programs for elderly persons, for injection drug users, and for immigrants—this is a justice violation and cannot be simply chalked up to differing priorities if one can demonstrate that it is systematic.

In addition, there appears to be relatively scant attention in the scholarly literature to the possibility that some public health actions can do harm. It is interesting that in public health there is not an analogue to the Hippocratic Oath from medicine (“first of all, do no harm”).19 If we wish to avoid doing harm in public health, we must (a) avoid public health errors and (b) reduce public health adverse events (be they a result of error or of human limitations) by developing systems of tracking and accountability. Indeed, reduction of such errors involves clearly defining, tracking, and developing interventions to address them. I submit that left unchecked, public health errors may well be costing lives, millions at a time.


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