Richard Flagg drowned in his own blood.

Stanley Stinnett choked on his own vomit.

Both were victims of the leading cause of accidental death in America -- mistakes made in medical care.

Experts estimate that a staggering 98,000 people die from preventable medical errors each year. More Americans die each month of preventable medical injuries than died in the terrorist attacks of Sept. 11, 2001.

In addition, a federal Centers for Disease Control and Prevention study concluded that 99,000 patients a year succumb to hospital-acquired infections. Almost all of those deaths, experts say, also are preventable.

These numbers are not absolutes. There is no definitive study -- which is part of the problem -- but all available research indicates that the death toll from preventable medical injuries approaches 200,000 per year in the United States.

Ten years ago, a highly publicized federal report called the death toll shocking and challenged the medical community to cut it in half -- within five years.

Instead, federal analysts believe the rate of medical error is actually increasing.

A national investigation by Hearst Newspapers found that the medical community, the federal government and most states have overwhelmingly failed to take the effective steps outlined in the report a decade ago.

Consequently, over that period, as many as 2 million Americans have died needlessly of preventable medical mistakes.

Secrecy built into the system has kept both the scope of the crisis and problem hospitals out of public view.

A Hearst data analysis lifted a corner of that veil of secrecy to show that in five states served by Hearst newspapers -- New York, California, Texas, Washington and Connecticut -- only 20 percent of 1,434 hospitals surveyed participate in two national safety campaigns.

Also, a detailed safety analysis prepared for Hearst Newspapers examined discharge records from 1,832 medical facilities in four of those states. It found that 16 percent of hospitals had at least one death from common procedures gone awry -- and some had dozens.

Now, as the Obama administration wrangles with Congress over health care access, frustrated patient-safety leaders say another priority must finally be addressed -- making hospitals safer.

Back in November 1999, the report titled "To Err Is Human" was issued with the highest of hopes. Its authors believed it promised the start of a revolution in patient safety.

The report sparked awareness of the problem's scale. But some of its authors say the revolution was doomed by a lack of political leadership and the health care lobby's vested interest in maintaining business as usual, especially secrecy surrounding dangerous medical errors.

"We didn't have any government efforts. We didn't show leadership and take charge and do what needed to be done," said Dr. Lucian Leape, one of the authors of "To Err is Human," and who is considered the father of the modern patient safety movement.

The report marked the first time that an authoritative voice -- backed by the national Institute of Medicine -- urged the industry and critics alike to stop blaming doctors and nurses. People make mistakes, the report said, so medicine must design systems that reduce errors and prevent harm from reaching the patient when a mistake is made.

Like a car ignition that won't release the keys until a driver shifts into park, the safe systems envisioned by the authors make it easy for health care workers to do the right thing.

No nationwide system

"To Err is Human" called for a mandatory nationwide reporting system for medical errors. That never happened.

"The (American Medical Association) came out foaming at the mouth," said Arthur Levin, president of the Center for Medical Consumers and an author of "To Err is Human." "And I think the decision was made to let it fall off the table because the wisdom was that you needed the cooperation of the profession to make progress. I think the tacit compromise was, 'We'll let that go.'"

The AMA and the American Hospital Association vehemently opposed an attempt by President Bill Clinton to create a mandatory reporting system for serious errors. The leaders of both groups snubbed an invite to a White House news conference introducing the president's patient safety agenda in 2000.

Mandatory reporting was dead on arrival.

By contrast, Americans know exactly how many people die from car accidents each year because lawmakers decided long ago that was a step toward preventing them. Motor vehicle deaths are the No. 1 cause of accidental death in the United States, with more than 43,600 deaths in 2006, according to the CDC. The next three causes -- poisoning, firearms and falls -- account for 90,000 deaths, combined.

But it is clear that if medical errors and infections were better tracked, they would easily top the list. A visit to your doctor or a hospital is twice as likely to result in your death as does a drive on America's highways.

A sorry scorecard

It's revealing to review other key recommendations from "To Err is Human" in the context of what has been done in the 10 years since they were made. The report:

Encouraged states to require medical error reporting. Only 20 states plus the District of Columbia have done so, and evidence shows that even in those mandatory-reporting states, hospitals report only a tiny percentage of their mistakes.

Said the public "has the right to be informed about unsafe conditions." But 45 states plus the District of Columbia don't provide hospital-specific information.

Recommended the creation of a national patient safety center. The center is underfunded and has fallen far short of expectations.

Urged hospitals to improve safety within their walls. Hundreds of hospitals responded, several comprehensively pursuing safer care. Thousands did much less.

Advocated a voluntary system for hospitals to report and learn from errors. Five years later, Congress approved legislation for "patient safety organizations" to serve this role, then took four more years to create rules to govern them. But the new organizations are devoid of meaningful oversight and further exclude the public.

Progress, but not enough

Positive developments are overshadowed by the continuing death toll.

Hearst Newspapers interviewed 20 of the 21 living authors of "To Err is Human," and 16 believe the U.S. hasn't come close to reducing medical errors by half. Four did not know or declined to answer because they are removed from the world of patient safety.

In its 2008 annual report to Congress, the Agency for Healthcare Research and Quality, a part of the Department of Health and Human Services, reported that preventable medical injuries are growing each year by 1 percent.

AHRQ's analysis showed that more people suffered accidental tears to their organs during surgery, more patients developed avoidable bloodstream infections from catheters, and one out of seven hospitalized Medicare patients experienced at least one adverse event during a hospital stay.

"Unfortunately, there hasn't been a significant improvement in the level of medical errors, and what is getting worse is hospital-based infections that are preventable," said Kathleen Sebelius, secretary of the Department of Health and Human Services, which oversees AHRQ, Medicare and the Food and Drug Administration.

Leape is frustrated by how few hospitals adopted 34 safe practices endorsed by the National Quality Forum, a coalition of medical groups. At a May conference of hospital leaders, Leape asked attendees to raise their hands if they had plans to implement all 34 practices. Three hands went up in a crowd of 175.

Poor safety performance

The safety analysis conducted on behalf of Hearst Newspapers by Niagara Health Quality Coalition, an independent nonprofit in Buffalo used discharge data from 1,832 medical facilities in New York, Washington, California and Texas. It found that nearly one in six of those facilities had preventable deaths from common procedures, including cases in which medical instruments were left inside patients and transfusions were done incorrectly.

It also found 399 of those hospitals had poor performance in at least one, and in some cases several, safety indicators developed by federal health researchers.

Deaths from medical injuries happen behind the doors of a hospital room. Unlike a widely publicized national tragedy that takes hundreds of lives in an instant, these deaths are singular and often secret.

Doctors fudge death certificates, leaving out information that would point to medical error as a cause of death, according to court records and other documents examined by Hearst reporters and graduate students at the Toni Stabile Center for Investigative Journalism at Columbia University's Graduate School of Journalism.

Norine Zazzara, 81, died of pneumonia at St. Joseph's Hospital in Syracuse, according to her initial death certificate. Hospital records show she went in for a shot to treat leg swelling. She contracted a MRSA infection, or methicillin-resistant Staphylococcus aureus, and developed pneumonia. After weeks on a ventilator, she died.

Her daughter, Betsy Zazzara, persuaded her doctor to change the death certificate to reflect the infection. She said the doctor asked whether it mattered what the death certificate said. "Yes," she replied. "One of these days they may start counting these people who have died of MRSA, and I want my mother to be counted."

The CDC -- which is supposed to track the nation's deaths and diseases -- is aware of the inaccuracies in death certificates.

Medical error is "often not reported," said Robert N. Anderson, chief of the CDC's Mortality Statistics Branch.

He said doctors aren't given enough motivation to report errors, and, because of liability, "it would cause them problems down the road, so that there is a disincentive to report it."

The 22 authors of "To Err is Human" debated public disclosure and fears that it would create more lawsuits and drive errors underground.

The authors, in the end, decided patients deserved the information.

"These are the kind of things the American public has the right to know about and that patients should know about when they are selecting a particular hospital or surgeon," said Janet Corrigan, who was the lead staff writer of "To Err is Human" and is now president of the National Quality Forum.

The Obama administration does not support a nationwide, mandatory reporting system.

"The best thing to do is to create the incentives and the knowledge around best practices to prevent the errors from ever occurring," Nancy-Ann DeParle told Hearst Television. DeParle is Obama's health adviser and director of the White House Office of Health Reform.

"If we prevent the errors from occurring, then we don't have to worry about … a massive reporting system," she said.

States' spotty records

Yet without a nationwide reporting system for medical accidents, states are left to collect the information themselves. The result is a chaotic, dysfunctional patchwork.

Hearst research shows that 20 states and the District of Columbia have mandatory reporting systems and five states are just setting up such systems. But only five of the 20 -- Washington, Massachusetts, Minnesota, Colorado and Indiana -- are transparent enough to be useful to consumers by revealing hospital names. Five states have, or are setting up, voluntary reporting.

Meanwhile, 20 states have no reporting whatsoever.

In states that do report, standards vary wildly and enforcement is often nonexistent.

New York's reporting system has run out of money and staff. The last public report it produced is four years old.

The law mandating reporting in Texas expired in 2007, and funding ran out. A new reporting law has been passed, but no funds have been allocated.

Washington State requires reporting but doesn't enforce that requirement -- and the Legislature didn't provide funds to analyze the results.

The inspector general of the Department of Health and Human Services sounded an alarm in December about the lack of uniformity in state systems. Differences in regulation and standards make state data "unsuitable … to identify national incidence and trends," the report said.

Little help for patients

So how do patients know which hospital is doing a good job? They don't.

AHRQ created software that mines hospital billing and discharge data volunteered by 40 states for adverse events. But AHRQ releases only aggregate information and promises states it will keep hospital-specific information secret.

The Centers for Medicare and Medicaid Services, a division of HHS, collects and publishes hospital-specific information on "processes of care." A care process involves actions like giving patients antibiotics before surgery -- practices that may influence infection but do not reveal a hospital's true infection rate.

"Too often in health care we measure effort, and we need to concentrate on results," said Bruce Boissonnault, president of Niagara Health Quality Coalition.

The Centers for Medicare and Medicaid Services' "Hospital Compare" Web site is silent on adverse events such as wrong-site surgeries and unexpected deaths during low-risk procedures -- all of which are within Medicare's ability to track.

Private groups fill gaps

The Institute of Healthcare Improvement recruited 2,000 hospitals to join its "5 Million Lives Campaign," which meant implementing 12 of the 34 safe practices. The institute publishes the names of participating hospitals.

The Leapfrog Group -- a nonprofit created by a "To Err is Human" author, Charles Buck, and other business executives -- attempts to measure hospital safety efforts. Many hospitals refuse to participate.

Boissonnault's Niagara Health Quality Coalition proves that hospital-specific safety measures can be published. Niagara posts mortality rates for 15 medical procedures and 14 safety measures for New York hospitals.

To get the information, Niagara analyzes hospital billing and discharge information -- the same data AHRQ collects but keeps secret.

More secrecy ahead

Under federal regulations issued on the last day of the Bush administration, medical practitioners can be fined $10,000 for publicly revealing information about their errors.

Candid information about dangerous events in hospitals will be funneled into top-secret "black boxes" -- dozens of privately run patient safety organizations around the country that will presumably analyze the information to improve medical operations, with little or no oversight.

The HHS stated that there will be "little direct federal involvement" in the patient safety organizations and no funding.

The organizations, which now number 65, are expected to reduce adverse events by 1 percent this year, rising to 3 percent by 2013, according to the Federal Register.

Ironically, the only enforcement provisions with teeth involve wrongful release of information about patient safety cases, which the HHS Office for Civil Rights will investigate.

"What's the public benefit? Supposedly, we are counting on the goodwill of hospitals," said Levin, the Center for Medical Consumers' president. "I'm not a believer. Show me the beef."

If patient safety improves, it will happen too late for too many, including Richard Flagg and Stanley Stinnett.

Surgeons at Meadowlands Hospital in Secaucus, N.J., accidentally removed Flagg's healthy lung, leaving behind a tumor in the 60-year-old's diseased lung, according to the state Board of Medical Examiners. The tumor bled and made him cough. Flagg survived three years, attached to oxygen, until the tumor ruptured and he drowned in his blood.

Stinnett, 49, entered the emergency room at Memorial Medical Center in Modesto, Calif., with broken ribs and left in a body bag.

A series of errors killed him -- starting with improper treatment of an intestinal obstruction, according to testimony from his family's medical experts. The drug oxycodone suppressed his gag reflex and his own vomit shut off his airway, one expert concluded. The doctor denied responsibility, but the jury awarded the family $8.5 million. The doctor is appealing.

Stinnett was, like many Americans, at one of his life's most vulnerable moments when he entered the hospital, and he didn't have much choice about his care. Even when people have choices, they usually have no information about a hospital's safety record.

"They did nothing for him but fill him with medication to let him die peacefully," said his widow, Holly Stinnett. "There was nothing wrong with him to begin with but four fractured ribs."

Will reform happen?

"There's a point at which you have to say, 'Is it ethical to allow preventable harm to continue to occur when you know how to prevent it?'" Levin said. "When do you say enough is enough?"

Contributing to this story were Olivia Victoria Andrzejczak, Kyla Calvert, Ana Azpurua, Andrew Schmid and Emily Witt of the Toni Stabile Center for Investigative Journalism at Columbia University; John Martin, adjunct professor, Columbia University Graduate School of Journalism; Sarah Hinman, director of news research, Albany Times Union; Laurie Kinney, reporter, Hearst Television; Terri Langford, enterprise reporter, Houston Chronicle; Lance Williams, investigations editor and reporter, San Francisco Chronicle; and Don Finley, medical writer, and Kelly Guckian, database editor, San Antonio Express-News.