Medical Mistakes Kill 100,000+ Americans A Year

If a Jumbo Jet crashed and killed 280 people everyday.. 365 days a year.. year after year.. would you be concerned about flying?? Would you question the Federal Aviation Administration? Would you demand answers?? Think about it .. close to 100,000 people dying every year from plane crashes. Sounds Ridiculous??!! 

Well think again.. what if you were told that over 100,000 people are killed and over 2 million people maimed and disabled every year .. year after year from modern medicine.. would you believe it?? 

Well these may be my words.. but read the following articles from the most respected medical journals and institutions (Journal of the American Medical Association, Harvard University, Centers for Disease Control, British medical journal The Lancet, New England Journal of Medicine and national news (New York Times, Washington Post, CNN, US World Report) and you be the judge.. 

Read on...................

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By Dena Bunis

Dec. 7, 1999 | Representatives from all quarters of the health-care debate came together in the White House Rose Garden Tuesday to get behind a pretty simple premise: Health-care workers shouldn't make the kind of mistakes that cost the lives of as many as 98,000 patients a year.

Flanked by representatives of the health-care industry, business, labor and government, President Clinton signed an executive memorandum directing his health-care quality task force to analyze last week's Institute of Medicine study that quantified the deaths attributable to medical errors, many of them as a result of wrong prescription-drug doses.

The independent study estimated that medical mistakes kill between 44,000 and 98,000 Americans each year. About 7,000 deaths were attributed to errors in prescribing or dispensing drugs. The IOM found flaws in the way hospitals, clinics and pharmacies operate. "Once you know about a problem, you're under a moral obligation to deal with it," Clinton said when asked whether admitting mistakes might expose health-care professionals to increased lawsuits. "Whatever the consequences are, we have to go forward."

========== Health care's deadly secret: Accidents routinely happen   By Andrea Gerlin INQUIRER STAFF WRITER Walter Nawracay died after brain surgery. The Medical College of Pennsylvania Hospital is a typical teaching hospital. It is known for cutting-edge research programs, for training medical students and newly graduated doctors, and for providing advanced medical care. It is also representative of modern American hospitals in another respect: In the last decade alone, records show, hundreds of MCP Hospital patients have been seriously injured, and at least 66 have died after medical mistakes. The hospital's internal records cite 598 incidents reported by medical professionals to the hospital administration in the last decade. In some of those cases, patients or survivors were never told that the injuries were caused by medical errors. None of the doctors involved in the incidents was subjected to disciplinary action. For patients of all ages, serious injury and death caused by medical errors are well-known facts of life in the medical community. But they are rarely reported to the general public. MCP Hospital's records came to light only because of bankruptcy proceedings last year, when its new owner publicly filed a detailed account of the 598 incidents reported at the facility from January 1989 through June 1998. Those numbers mirror what is happening across the country. Lucian Leape, a Harvard University professor who conducted the most comprehensive study of medical errors in the United States, has estimated that one million patients nationwide are injured by errors during hospital treatment each year and that 120,000 die as a result. That number of deaths is the equivalent of what would occur if a jumbo jet crashed every day; it is three times the 43,000 people killed each year in U.S. automobile accidents. "It's by far the number one problem" in health care, said Leape, an adjunct professor of health policy at the Harvard School of Public Health. In their study, Leape and his colleagues examined patient records at hospitals throughout the state of New York. Their 1991 report found that one of every 200 patients admitted to a hospital died as a result of a hospital error. Researchers such as Leape say that not only are medical errors not reported to the public, but those reported to hospital authorities represent roughly 5 to 10 percent of the number of actual medical mistakes at a typical hospital. "The bottom line is we have a system that is terribly out of control," said Robert Brook, a professor of medicine at the University of California at Los Angeles. "It's really a joke to worry about the occasional plane that goes down when we have thousands of people who are killed in hospitals every year." Brook's recognition of the extent of hospital errors is shared by many of medicine's leaders. ==========

Study slams medical error rate in nation By Andrea Gerlin INQUIRER STAFF WRITER   A panel of the National Academy of Sciences, in a highly critical report, yesterday called for a major national effort to reduce medical errors by developing a mandatory reporting system and asking Congress to establish a center to study them. The 220-page report, written by a 19-member committee of the Academy's Institute of Medicine, set as a goal a 50 percent reduction in the nation's "stunningly high rate of medical errors" within five years. It estimated that errors from medical treatment kill up to 98,000 people in U.S. hospitals every year and characterized the problem as among the nation's leading causes of death and injury. Several members of the committee said in interviews yesterday that the report was intended as a loud call to action for the health-care industry, which it said has not acted swiftly enough to address the causes of errors. "What it says is 'enough already,' " said Lucian Leape, a committee member and adjunct professor of health policy at the Harvard School of Public Health. "It's a matter of holding people's feet to the fire and stop talking about errors and start doing something." ========== Medical mistakes often unreported About 3,500 patients die � and no one has to know By Sarah A. Webster / The Detroit News     Twenty states require hospitals to report serious mistakes, but Michigan isn�t among them. Morris Richardson II/ The Detroit News Colleen Chapman of Dearborn was overcome with emotion in a Wayne County court in December. She is suing a local hospital to learn what diseases she may have been exposed to because of a mistake in sterilizing an instrument used on her during surgery. As a result, it�s impossible to say exactly how many people are maimed or killed by hospital foul-ups. But based on a recent report by the Institute of Medicine, which estimates 36 error-related hospital deaths per 100,000 people, 3,534 Michiganians died last year due to medical mistakes.     Patients reported 2,027 complaints about health care organizations to the state, but Tom Lindsay, director of the Michigan Bureau of Health Services, said those likely represent just a fraction of the mistakes.     �I can�t tell you how many deaths or injuries result from medical mistakes,� Lindsay said.     Several institute members said mandatory reporting of serious mistakes is the first step to reducing the errors. It is asking Congress to establish a nationwide mandatory reporting system for medical errors that cause injury or death.

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MEDICAL MISTAKES

During 1999 mainstream institutions revealed that one of the
biggest killers in the U.S. is medical mistakes.

** The NEW YORK TIMES reported that 5% of people admitted to
hospitals, or about 1.8 million people per year, in the U.S. pick
up an infection while there.[1] Such infections are called
"iatrogenic" -- meaning "induced by a physician," or, more
loosely, "caused by medical care." Iatrogenic infections are
directly responsible for 20,000 deaths among hospital patients in
the U.S. each year, and they contribute to an additional 70,000
deaths, according to the federal Centers for Disease Control
(CDC). The dollar cost of iatrogenic infections is $4.5 billion,
according to the CDC.

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Washington Post

High-Tech Cure for Medical Mistakes

By Newt Gingrich
Wednesday, August 2, 2000; Page A31

Imagine that we had an airline crash every day, taking the lives of more than 250 Americans. The country would be outraged, the president would be demanding action, and Congress would be passing emergency legislation. And yet a tragedy of similar proportions is occurring right now in American hospitals.

As many as 98,000 people are needlessly dying in our hospitals every year because of inappropriate medical treatment, according to the report "To Err Is Human" by the Institute of Medicine (IOM). The number of people who die every day in hospitals because of inappropriate medicine is double the number who died in last week's Concorde crash.

The time has come for Congress and the president to act on behalf of all Americans. It is time to stop defending inefficiency and to drag health care into the 21st century by insisting on modern management and information systems.

According to IOM's initial report, inappropriate medical treatment is the fifth leading cause of death in the United States. And that number does not include deaths resulting from home care, ambulatory care or outpatient visits, those that occur in nursing homes or those at patients' homes after they have received inappropriate care in the hospital.

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Medical mistakes: A legal and ethical dilemma for doctors and patients

John Hawley had surgery in late January of 1998

May 1, 2000
Web posted at: 8:41 a.m. EDT (1241 GMT)

By CNN & Time Producer Ken Shiffman

Ask John Hawley about medical mistakes, and he'll tell you how he lost half a lung to a misdiagnosis of cancer. Ask his wife, and she'll tell you about the fear that she felt through the ordeal. They'll both tell you they were stunned that his doctors never told them about the mistake.

Experts say medical mistakes occur all the time, and doctors often fail to tell patients about them. A recent report estimates that up to 98,000 patients a year die from medical errors.

Hawley, a retiree from the U.S. Navy, went into surgery in late January 1998 at Lawnwood Regional Medical Center in Fort Pierce, Florida. Half of one lung was cut out, and tissue was sent to the pathology lab for a follow-up analysis.

For the year following the surgery, the Hawleys say they lived in fear, worrying that John's cancer might reoccur. The Hawleys say they were astonished to find out that allegedly the doctors had known, but had not told them, that the post-surgery pathology lab analysis had revealed that Hawley apparently had been misdiagnosed with cancer.

"I was tickled to death for about 30 seconds," says Hawley, "then I got really mad, figured that I went through all of this pain and been drug through everything, and back for appointments to see the people who done it, and they never mentioned a word to me. And I was pretty mad."

Hawley is suing Lawnwood hospital and some of its doctors. All the defendants declined to comment, citing the lawsuit.

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Deaths in England Due to Medical Errors up 500%

By Sarah Lyall

About 1,200 people died in public hospitals in Britain last year because of mistakes in prescribing and administering medicine, according to a report published by a government watchdog group.

Outlined in a report by the Audit Commission, the errors included administering the wrong medicine - in one case, a breast cancer patient was given the sleeping drug Temazepam instead of the cancer drug Tamoxifen - to giving out the wrong dosage of the right drug, to unknowingly prescribing a drug that caused a fatal reaction.

The death toll was five times higher than that in 1990, according to the report.

In addition, the thousands of patients who survive medicine-related mistakes each year invariably become sicker, requiring more treatment that create an extra expense for the National Health Service, the report said.

"The health service is probably spending $725 million a year making better people who experienced an adverse incident or errors, and that does not include the human cost to patients," said Nick Mapstone, an author of the report.

Mr. Mapstone said that many of the most common errors are avoidable and could be rectified if the health service introduced computerized patient record and prescription systems.

As it is now, patients' notes are often illegible, incomplete or missing altogether, the report said, making it impossible for doctors and nurses to have accurate information.

The government has promised to introduce computerized prescriptions - which could include a standard national system for coding medicines and the use of bar codes to support development of electronic prescribing systems - by 2005, but Mr. Mapstone said he did not think it would meet the deadline.

Addressing the issues raised by the report, Dr. Trevor Pickersgill, a spokesman for the junior doctors' committee of the British Medical Association, said that understaffing in hospitals and the increasing complexity of modern drug therapy have created a culture "where mistakes unfortunately do happen."

"The number of drugs is increasing, the effectiveness - and therefore often the toxicity - of drugs is increasing, the number of people on multiple medications is increasing, and that increases the risk of interaction," Dr. Pickersgill told the BBC.

"We must also remember that one in six pharmacy posts in hospitals are unfilled, and new doctors who are doing the work on the wards are overworked as well," he said.

A number of highly publicized cases of drug-related error in recent months has brought home the problem. In one case, a cancer patient was prescribed and administered a drug at 1,000 times the recommended dose, according to the report.

In another case, at Queen's Medical Center in Nottingham, a teenager, who was a cancer patient in remission, fell into a coma and died after an anticancer drug was mistakenly injected into his spine.

"The recent events at Queen's Medical Center illustrate how day-to- day pressures can lead to acknowledged best practice being ignored," the report said.

Jackie Glatter, a spokeswoman for the Consumers' Association, which lobbies for patients' rights, said: "The report shows there is a strong need for detailed and clear patient information about treatments and medicines - not just in hospitals, but also when people are taking medicine at home."

New York Times December 20, 2001

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Medical errors kill tens of thousands annually, panel says Anesthesiologists made their field safer by getting manufacturers to standardize equipment   November 30, 1999 Web posted at: 12:20 a.m. EST (0520 GMT) WASHINGTON (CNN) -- More people die each year in the United States from medical errors than from highway accidents, breast cancer or AIDS, a federal advisory panel reported Monday. The report from the National Academy of Sciences' Institute of Medicine cited studies showing between 44,000 and 98,000 people die each year because of mistakes by medical professionals. "That's probably an underestimate for two reasons," noted Dr. Donald Berwick of the Institute of Medicine. "One is, there are many different kinds of errors we never learn about -- even in retrospective studies -- because they are never written down. And second, these studies did not include other areas of care like home care, nursing homes and ambulatory care centers," Berwick said. ==========

Report: Deaths from medication errors on increase

(CNN) -- Deaths caused by medication mistakes more than doubled between 1983 and 1993, according to findings published in the British medical journal The Lancet on Saturday.

The study by a research team at the University of California at San Diego found that the sharpest increase in deaths was among outpatients.

Deaths from accidental poisoning by drugs and other medicines climbed from 851 to nearly 2,100. Of those, outpatient deaths increased from under 200 to just under 1,500. By 1993, outpatients were 6.5 times more likely to die from medication mistakes than inpatients.

The report was based on death certificates, and it was unclear whether the deaths were caused by a medical professional's error or patient error.

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Study: Drug reactions kill an estimated 100,000 a year

 

CHICAGO (CNN) -- Adverse reactions to prescription and over-the-counter medicines kill more than 100,000 Americans and seriously injure an additional 2.1 million each year, researchers say.

Such reactions -- which do not include prescribing errors or drug abuse -- rank at least sixth among causes of death in the United States, behind heart disease, cancer, lung disease, strokes and accidents, according to a report published in this week's Journal of the American Medical Association. The report was based on an analysis of existing studies.

"Serious adverse drug reactions are frequent ... more so than generally recognized," the researchers said.

Researchers at the University of Toronto examined 39 studies and estimated that an average of 106,000 deaths at U.S. hospitals in 1994 were due to bad reactions to drugs.

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Medical Mistakes Triple All Gun Deaths

     Nov. 30 update -- For years, the American Medical Association,
hospitals, medical magazines and various other health care groups
have been beating the drums for more gun laws.  

    And some of us have pointed out their chutzpah, since -- according 
to the official figures, the National Center for Health Statistics, more than 
twice as many are killed every year in medical accidents than in gun
accidents.

     Some experts have long said the real numbers of what are
euphemistically called "Medical Misadventures" are many times
higher than officially acknowledged.

     Yesterday, an independent report from the Institute of
Medicine, an arm of the National Academy of Sciences, said the
number of deaths from medical mistakes every year may total 98,000
-- about three times the number of deaths due to accidents, homicides 
and suicides with firearms.

     The study says medical mistakes may cost the nation as much as
$29 billion a year and may be the fifth highest cause of death --
behind heart disease, cancer, stroke and lung obstructive lung
diseases.

    That 98,000 total is over twice as many as die in auto
crashes each year.

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Nursing mistakes kill, injure thousands

Cost-cutting exacts toll on patients, hospital staffs

By Michael J. Berens
Tribune Staff Writer
September 10, 2000

Overwhelmed and inadequately trained nurses kill and injure thousands of patients every year as hospitals sacrifice safety for an improved bottom line, a Tribune investigation has found.

Since 1995, at least 1,720 hospital patients have been accidentally killed and 9,584 others injured from the actions or inaction of registered nurses across the country, who have seen their daily routine radically altered by cuts in staff and other belt-tightening in U.S. hospitals.

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By Lois Rogers

MEDICAL error is the third most frequent cause of death in Britain after cancer and heart disease, killing up to 40,000 people a year - about four times more than die from all other types of accident. Provisional research figures on hospital mistakes show that a further 280,000 people suffer from non-fatal drug-prescribing errors, overdoses and infections. The victims spend an average of six extra days recovering in hospital, at an annual cost of �730m in England alone.

A pilot study investigating the issue - the first attempt to measure the problem in Britain - shows that one in 14 patients suffers some kind of adverse event such as diagnostic error, operation mistake or drug reaction. Charles Vincent, head of the clinical risk unit at University College London, who is leading the study, has pioneered efforts to examine the extent of clinical errors in Britain. His team has so far concentrated on two London hospitals. The first data from one hospital showed that 32 out of 480 patients in four different departments were victims of hospital mistakes.

Vincent's estimate of 40,000 deaths comes from studies showing that 3-4% of patients in the developed world suffer some kind of harm in hospital. For 70% of them the resulting disability is short-lived, but 14% subsequently die. "It is a substantial problem," Vincent said. "There is a need to find out the true extent of error, what kind of things are going wrong and the cost." He believes the death rate may be even higher than indicated by the preliminary figures.

Britain's death rate is comparable to that in America, where recommendations in a report produced by the Kellogg Foundation three weeks ago are likely to result in the creation of a new federal agency to protect patients from medical error

The report drew on studies that examined the records of 30,195 patients and found a 3.7% error rate. Of those injured, 14% died. Researchers concluded that 70% of the errors - and 155,000 deaths - were avoidable.

Department of Health officials are now examining a proposal for a �1.2m three-year national study of 20 hospitals and 10,000 medical records to establish exactly how these avoidable deaths occur and how to prevent them.

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In a recent emailed response to the British Medical Journal (BMJ), Ron Law, Executive Director of the NNFA, in New Zealand and member of the New Zealand Ministry of Health Working Group advising on medical error, offered some enlightening information on deaths caused by drugs and medical errors.

He notes the prevalence of deaths from medical errors and also from properly researched and prescribed medications in Australia and New Zealand, which serves as a reminder to us that the US is not alone in having this problem.

He cites the following statistics and facts:

• Official Australian government reports reveal that preventable
  medical error in hospitals is responsible for 11% of all deaths in Australia.(1, 2), which is about 1 of every 9 deaths.
  

• If deaths from properly researched, properly registered, properly prescribed and properly used drugs were added along with preventable deaths due to private practice it comes to a staggering 19%, which is almost 1 of every 5 deaths.

• New Zealand figures are very similar.

According to Mr. Law:

Put another way, the equivalent of New Zealand's second largest city (Christchurch) has been killed by preventable medical error and deaths from properly researched, properly registered, properly prescribed and properly used drugs in Australasia in the past decade and its biggest city Auckland either killed or permanently maimed. 

Put another way, more than 5 milion people have been killed by Western medical practice in the past decade (Europe, USA, Canada, Australia, and NZ) and 20 million killed or permanently maimed. Sounds like a war zone, doesn't it?

Put another way, the economic impact of deaths due to preventable medical error and deaths from properly researched, properly registered, properly prescribed and properly used drugs is approximately $1 trillion over the past decade.

He notes that only 0.3% of these deaths are properly coded and classified in official statistics as being attributed to these causes.

British Medical Journal November 11, 2000; 321: 1178A (emailed response)

References:

1. Iatrogenic Injury in Australia - This is the executive summary of a 150 page official report revealing 14,000 preventable medical error deaths (only in hospitals - not private practice). (Full report on file).

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Study: Tools left in 1,500 patients yearly

By Jeff Donn
The Associated Press

BOSTON � Surgical teams accidentally leave clamps, sponges and other tools inside about 1,500 patients nationwide each year, according to the biggest study of the problem yet.

The mistakes largely result not from surgeon fatigue, but from the stress arising from emergencies or complications discovered on the operating table, the researchers reported.

It also happens more often to fat patients because there is more room inside them to lose equipment, according to the study.

Both the researchers and several other experts agreed that the number of such mistakes is small compared with the roughly 28 million operations a year in the United States. "But no one in any role would say it's acceptable," said Dr. Donald Berwick, president of the Boston-based nonprofit Institute for Healthcare Improvement.

The study was done by researchers at Brigham and Women's Hospital and Harvard School of Public Health, both in Boston. It was published in today's New England Journal of Medicine.

The researchers checked insurance records from about 800,000 operations in Massachusetts for 16 years ending in 2001. They counted 61 forgotten pieces of surgical equipment in 54 patients. From that, they calculated a national estimate of 1,500 cases yearly. A total of $3 million was paid out in the Massachusetts cases, mostly in settlements.

Two-thirds of the mistakes happened even though the equipment was counted before and after the procedure, in keeping with the standard practice.

Most lost objects were sponges, but also included were metal clamps and electrodes. In two cases, 11-inch retractors � metal strips used to hold back tissue � were forgotten inside patients.

The lost objects often caused tears, obstructions or infections. One patient died of complications, but the researchers withheld details for reasons of privacy.

Most patients needed additional surgery to remove the object.

The study found that emergency operations are nine times more likely to lead to such mistakes, and that operating-room complications requiring a change in procedure are four times more likely. A rise of one point in the patient's body-mass index, a measure of weight relative to height, raises the chances of such a mistake by 10 percent.

The length of the operation or the hour of day does not appear to make a difference, suggesting that fatigue does not cause such mistakes.

"It tends to be in unpredictable situations," said lead author, Dr. Atul Gawande of Brigham and Women's Hospital.

Dr. Sidney Wolfe, health-research director of the public-interest lobby group Public Citizen, said the real number of lost instruments may be even higher, because hospitals are not required to report such mistakes to public agencies.

However, others said such mistakes are so rare � occurring about 50 times in 1 million operations � that figuring out how to prevent them could be difficult.

"I find it's going to be difficult to make much more improvement, because some of the risk factors are things that are hard to control," said Lori Bartholomew, research director at the Physician Insurers Association of America, which represents medical-malpractice insurers.

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Drugs and Doctors May be the Leading Cause of Death in U.S.

By Joseph Mercola, D.O.

This finding is more of a speculation though, so below I have provided some other studies to support this assertion.

 

• In 1994, an estimated 2,216,000 (1,721,000 to 2,711,000) hospitalized patients had serious adverse drug reactions (ADRs) and 106,000 (76,000 to 137,000) had fatal ADRs, making these reactions between the fourth and sixth leading cause of death.

• Fatal ADRs accounted for 0.32 percent (95 percent confidence interval (CI), 0.23 percent to 0.41 percent) of hospitalized patients.

JAMA April 15, 1998;279(15):1200-5

Serious and Fatal Drug Reactions in US Hospitals

• Drug-related morbidity and mortality have been estimated to cost more that $136 billion a year in United States. These estimates are higher than the total cost of cardiovascular care or diabetes care in the United States. A major component of these costs is adverse drug reactions (ADE).

Healthsentinel.com

• The numbers of deaths reported in data sets varied 34-fold and were up to several 100-fold less than values based on extrapolations of surveillance programs.

Am J Med August 1 2000;109(2):122-30

 

• About 0.05 percent of all hospital admissions were certainly or probably drug-related.

• Incidence figures based on death certificates only may seriously underestimate the true incidence of fatal adverse drug reactions.

Eur J Clin Pharmacol October 2002;58(7):479-82

 

• In one study of 200 patients, ADRs may have contributed to the deaths of two (one percent) patients.

J Clin Pharm Ther October 2000;25(5):355-61

• In a survey of over 28,000 patients, ADRs were considered to be the cause of 3.4 percent of hospital admissions. Of these, 187 ADRs were coded as severe. Gastrointestinal complaints (19 percent) represented the most common events, followed by metabolic and hemorrhagic complications (nine percent). The drugs most frequently responsible for these ADRs were diuretics, calcium channel blockers, nonsteroidal antiinflammatory drugs and digoxin.

J Am Geriatr Soc Dec 2002;50(12):1962-8

Comments by Dr. Mercola

As health reporter Nick Regush said last year

"There is no way to be nice about this. There is no point in raising false hopes. There is no treatment or vaccine in sight. There is no miracle breakthrough on the horizon.

Medicine, as we know it, is dying. It's entering a terminal phase.

What began as an acute illness reached the chronic stage about a decade ago and progression toward death has been remarkably swift and well beyond anything one could have predicted.

The disease is caused by conflict of interest, tainted research, greed for big bucks, pretentious doctors and scientists, lying, cheating, invasion by the morally bankrupt marketing automatons of the drug industry, derelict politicians and federal and state regulators - all seasoned with huge doses of self-importance and foul odor."

Currently, the United States spends about 1.5 trillion dollars for healthcare, and the projections are that it will double in less than 10 years.

The sad tragedy is that we are spending all of this money on disease management focused on drugs and surgery, and our return on this investment is profoundly poor. More and more people do not have the energy they need to get through the day while millions of others are suffering with painful crippling diseases because they have violated basic health principles.

Often, negative health and lifestyle choices are made because of a lack of knowledge, and it's my passion to increase the public's awareness of the health tragedies facing the nation. I will give you, the consumer, the tools to become a major force for good health and to alleviate disease and suffering.

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Dr. Grisanti's Comments:

There are literally thousands of news articles informing the public to be careful!! It is about time we take a stand on protecting our lives. The days of simply masking the symptoms has become a dangerous business. I believe the public must be informed and educated on alternatives to conventional medical treatment. I am very disappointed with the state of our country's health affairs.. If it is up the pharmaceutical industry to educate us, then the public will have a LONG wait. I am confident the people of our country will NEVER be offered time tested alternatives to drug therapy. Ultimately, your health rests in your hands.. My mission is to offer each and every one of my subscribers the most up-to-date alternative medical solutions. information I promise you won't see advertised on TV or your popular magazines..

References

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3. Starfield B.  Primary Care: Balancing Health Needs, Services, and Technology.  New York, NY: Oxford University Press, 1998.
4. World Health Report 2000.  Available at http://www.who.int/whr2001/2001/archives/2000/en/index.htm.  Accessed June 28, 2000.
5. Kunst A.  Cross-National Comparisons of Socioeconomic Differences in Mortality.  Rotterdam, the Netherlands: Erasmus University; 1997.
6. Law M, Wald N.  Why heart disease mortality is low in France:  The time lag explanation.  BMJ. 1999; 313:1471-1480.
7. Starfield B.  Evaluating the State Children's Health Insurance Program: critical considerations.  Annual Rev. Public Health. 2000; 21:569-585.
8. Leape L.  Unnecessary surgery.  Annual Rev. Public Health. 1992; 13:363-383.
9. Phillips D, Christenfeld N, Glynn L.  Increase in U.S. medication-error deaths between 1983 and 1993.  Lancet, 1998; 351:643-644.
10. Lazarou J, Pomeranz B, Corey P.  Incidence of adverse drug reactions in hospitalized patients.  JAMA. 1998; 279:1200-1205.
11. Weingart SN, Wilson RM, Gibberd RW, Harrison B.  Epidemiology and medical error.  BMJ. 2000; 320:774-777.
12. Wilkinson R.  Unhealthy Societies: The Afflictions of Inequality.  London, England: Routledge; 1996.
13. Evans R, Roos N.  What is right about the Canadian health system?  Milbank Q. 1999; 77:393-399.
14. Guyer B, Hoyert D, Martin J, Ventura S, MacDorman M, Strobino D.  Annual summary of vital statistics, 1998.   Pediatrics. 1999; 104:1229-1246.
15. Harrold LR, Field TS, Gurwitz JH.  Knowledge, patterns of care, and outcomes of care for generalists and specialists.  J Gen Intern Med. 1999; 14:499-511.
16. Donahoe MT.  Comparing generalist and specialty care: discrepancies, deficiencies, and excesses.  Arch Intern Med. 1998; 158:1596-1607.
17. Anderson G, Poullier J-P.  Health Spending, Access, and Outcomes: Trends in Industrialized Countries.  New York, NY: The Commonwealth Fund; 1999.
18. Mold J, Stein H.  The cascade effect in the clinical care of patients.  N Engl J Med. 1986; 314:512-514.
19. Shi L, Starfield B.  Income inequality, primary care, and health indicators.  J Fam Pract.1999; 48:275-284.

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