Letter to CDC: Need ICD Code for Medical Errors

Letter to CDC: Need ICD code for Medical Errors

This is a letter sent by Johns Hopkins University hospital to the CDC pointing out the need for a separate code to identify the frightening number of medical errors so they can be properly counted.

RE: Methodology used for collecting national health statistics

We are writing this letter to respectfully ask the Centers for Disease Control and Prevention (CDC) to change the way it collects our country’s national vital health statistics each year.  

The list of most common causes of death published is very important–it informs our country’s research and public health priorities each year.

The current methodology used to generate the list has what we believe to be a serious limitation. As a result, the list has neglected to identify the third leading cause of death in the U.S.—medical error.

The limitation stems from a historic policy that says death certificates can only be tabulated with an ICD billing code.

Apparently, there is no ICD code for “medical error”

We define death due to medical error as death due to

1) an error in judgment, skill, or coordination of care,

2) a diagnostic error,

3) a system defect resulting in death or a failure to rescue a patient from death, or

4) a preventable adverse event.

The prevalence of death due to medical error leading to patient deaths has been established in the literature.

From studies that analyzed documented health records, we calculated a pooled incidence rate of 251,454 deaths per year.(1) If we project this quantity into the total number of deaths in the year 2013 (2,596,993 deaths), they would account for 9.7% of all deaths in the nation.(2)

This figure far surpasses the current third leading cause of death on the CDC’s most recent rank order. Moreover, the 251,454 estimate we derived from the literature is an underestimate because the studies conducted did not include outpatient deaths or deaths at home due to a medical error.

See Estimate of Patient Harms in Hospital Care

Currently, the CDC uses a deaths collection system that only tallies causes of death occurring from diseases, morbid conditions, and injuries.(3)

The information on death certificates filled out by physicians, funeral directors, medical examiners, and coroners form the basis of an annually updated list of the most common causes of death.

We found that the death certificate form has a major limitation. Since 1949, when the U.S. adopted the International Form of Medical Certificate of Cause of Death, the CDC has tabulated the national mortality statistics by assigning an International Classification of Disease (ICD) billing code to the cause of death.(4)

As a result, causes of death not associated with an ICD code, such as human and system factors in medical care, are not captured. While current system is consistent with World Health Organization (W.H.O.) guidelines, allowing common measurement definitions between countries, the U.S. should be a leader in recognizing the role of medical error in national health statistics.

We suggest that the CDC allow clinicians to list medical error as the cause of death, and, in the interim, the CDC should list medical error as the third most common cause of death in the U.S. after heart disease (611,105 deaths per year) and cancer (584,881 deaths per year) and replacing respiratory disease (149,205 deaths per year).(2)

The U.S. government and private sector spend a lot of money on heart disease research and prevention. They also spend a lot of money on cancer research and prevention.

It is time for the country to invest in medical quality and patient safety proportional to the mortality burden it bears.

This would mean research in

1) technology that reduces harmful and unwarranted variation in medical care,

Again, seeking standardization is a mistake in the medical arena which is being addressed by the Precision Medicine Initiative, which seeks to tailor medical care to an individual’s unique makeup.

2) the non-technical (behavioral) and communication skills that prevent harm,

3) ways to improve the diagnostic accuracy, and

4) the prevention before and rescue after a preventable adverse event.

Each year, the U.S. Agency for Healthcare Research and Quality receives thousands of project proposals aimed at reducing preventable harm, but very few ever get funded because funding work on the delivery of care has historically taken a back seat to funding new treatments.

There’s little money to be made by improving all multiple cascading factors which eventually lead to patient harm.

Based on the prevalence of the problem of poor quality medical care, the human suffering and price tag due to error are significant and merits proportional funding.

Creating one additional field on the death certificate form to inquire if immediately preventable complications stemming from the patient’s medical care was the primary contributor to the patient’s death would advance the science of safety.

This information should also have the same medico legal protection that currently protects hospital quality improvement data from legal discovery.  

Appropriately recognizing the role of medical error in health care has enormous implications for medicine.

Drawing on reliable data, deaths from care, rather than from the disease that brought the person into care, should be addressed with the same resources and vigor as other scientific endeavors.

At minimum, listing the death burden of medical error would help create an open dialog about the problem.

Currently, deaths due to medical error result only in internal discussions in confidential forums such as a hospital’s internal root cause analysis committee or a department’s morbidity and mortality conference.

These forums review only a fraction of detected adverse events and the lessons learned are rarely disseminated beyond the borders of a single department or institution.

We need more honest conversations about the problem.

All financial, employment, and reputational incentives are aligned to encourage hiding errors, so there’s little motivation to expose them.

The CDC’s annual list of most common causes of death in the U.S. should strive for accuracy. It informs our country’s national funding campaigns.

An accurate list is important to appropriately shape the trajectory of public health initiatives in areas where the most people are being affected.

Increasing the transparency of the magnitude of the problem can lead to the design of safer systems mitigating their frequency, visibility, and consequences in both the U.S. and internationally.  

Reducing costly medical errors is critical towards the important goal of creating a safer, more reliable health care system.

Measuring and understanding the problem is the first step.

For a healthcare system so steeped in metrics, I find it strange that this metric has remained unidentified and uncounted.

It seems the most enthusiastic proponents of metrics become recalcitrant when asked to provide metrics of their own performance.


Sarah Joo
Medical Student, Johns Hopkins University School of Medicine

Michael Daniel
Medical Student, Johns Hopkins University School of Medicine

Tim Xu MPP
Medical Student, Johns Hopkins University School of Medicine

Martin A. Makary M.D., M.P.H., F.A.C.S.
Professor of Surgery and Health Policy & Management
Johns Hopkins University School of Medicine

Literature Cited:

  1. Makary MA, Daniel M. Medical Error: The Third Leading Cause of Death in the United States. BMJ. May 4, 2016.
    See “Hospital medical errors third leading cause of death in the U.S.
  2. Deaths: Final Data for 2013. National Vital Statistics Report. [Internet]. 2016 Mar; Available  from: http://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm
  3. ICD-10 Volume-2 Instruction Manual (2010). World Health Organization. Published via: http://www.who.int/classifications/icd/ICD10Volume2_en_2010.pdf
  4. Moriyama IM, Loy RM, Robb-Smith AHT, et. al. History of the Statistical Classification of Diseases and Causes of Death. National Center for Health Statistics. 2011 March; 1-71.


Other thoughts?

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

This site uses Akismet to reduce spam. Learn how your comment data is processed.