On December 1, 1999, the Institute of Medicine released a report entitled To Err is Human: Building a Safer Health System. Although its authors hoped to spark a national movement, they had little cause for optimism. After all, early efforts by advocates like Berwick and Leape and organizations like the National Patient Safety Foundation had barely moved the needle of public and professional attention.
The IOM Report succeeded beyond its framers’ wildest dreams, and the movement they spawned turns ten today. Please indulge me while I spend a nostalgic moment recalling the remarkable spin that launched the patient safety field. I’ll then segue to a summary of my assessment of what we’ve accomplished over the past decade (I outline this more fully in an article in this week’s web version of Health Affairs, which I hope you’ll take a look at).
In Internal Bleeding, after describing the history of the IOM (founded in 1970 as the National Academy of Science’s think tank for healthcare issues) and the fact that the venerable organization was not exactly known for its eye-popping PR, Kaveh Shojania and I wrote:
So one could not help but be taken aback by the screaming headlines that leapt off the book jacket of the [IOM Report]. One part Constitution Avenue to three parts Madison Avenue, its tone instantly caught the attention of the general populace and the media. Just consider the breathless prose of the book jacket, more like the trailer for a Hollywood blockbuster than the synopsis of an academic report:
Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That’s more than die from motor vehicle accidents, breast cancer, or AIDS—three causes that receive far more public attention…. This volume reveals the often-startling truth of medical error and the disparity between the incidence of error and public perception of it…
As if that wasn’t enough pizazz, the authors converted the staggeringly large but potentially bloodless “44,000-98,000 deaths per year” figure into the now-famous “Jumbo Jet Units” – making the point that the number of deaths from medical mistakes was the equivalent of a large plane crashing every day.
Although some have critiqued the “crash-a-day” spin as hyperbolic, I continue to believe it was masterful. Something was necessary to shake us out of our collective inattention, and it took the Jumbo Jet analogy to do it. (And just consider what our response would be if, in fact, a commercial airliner crashed for “just” two or three days in a row!) The IOM Report received saturation media coverage for several days, after which more than 50% of Americans surveyed were familiar with the epidemic of medical errors. In one bold stroke, medical mistakes joined airline and food safety (and, two years later, terrorism) as enduring sources of angst in the American zeitgeist.
While there are many metrics of the IOM Report’s impact, my favorite is this: even today, one can say “The IOM Report” and most folks will understand the reference to To Err is Human. This, despite the fact that the IOM has published 526 reports since To Err is Human. Want more: a Google search on “Institute of Medicine Report” pulls up the IOM’s website as the first hit; To Err is the second.
That’s all well and good, but what have we actually accomplished? In today’s Health Affairs article, I present my view of the progress we’ve made in the patient safety field’s first decade. I give us an overall grade of B-, a slight increase from the C+ I awarded 5 years ago in a similar Health Affairs paper.
In writing today’s article, I was struck by the emergence of state reporting systems, centered around the National Quality Forum’s list of “never events,” as the key maneuver that got safety reporting off the ground, and the increased safety activity within hospitals (many of which now have fairly effective patient safety enterprises) and national organizations (such as the NQF and AHRQ). On the other hand, it is remarkable how little progress we’ve made in IT (particularly when you contrast it with the breathtaking progress we’ve made in IT in virtually every other part of our personal and professional lives), and how we’re just beginning to grapple with balancing “no blame” and accountability. And, as I feared, regulators and accreditors are facing increasing challenges, as the low-hanging fruit (such as abolishing high-risk abbreviations) has been picked, leaving them struggling to improve performance in highly complex, nuanced areas like safety culture, medication reconciliation, and addressing problems caused by disruptive caregivers.
Many people will look at the past 10 years and wonder whether we’ve accomplished much of anything. I sympathize with this concern, one that’s partly driven by our maddeningly limited ability to measure progress in safety. Yet as I wander around my own medical center, signs of progress are unmistakable. Our safety enterprise is much more vigorous than it was five years ago (it was nonexistent 10 years ago). Despite some major IT snafus, we are using an electronic health record, and it is a far better way of communicating information than via snippets of chicken scratch penned on dead trees. During a weekly two-hour meeting, we analyze serious errors and review progress in fixing the unsafe conditions we uncover. Our residents and students are (mostly enthusiastically) participating in new safety and quality curricula. We are measuring safety outcomes such as healthcare-associated infections and reporting these results regularly at the highest levels of the organization. All good stuff.
Yes, there is much more for us to do. Patients everywhere are still harmed by preventable infections, falls, communication glitches, wrong-site surgery, medication mix-ups, and more.
But that’s for tomorrow. Today, let’s also take a moment to celebrate all the good work over the past ten years. In fact, had you asked me on December 1, 1999 how much progress would be possible in the next decade, my guess would have markedly underestimated what we actually have accomplished. As I visit hospitals and healthcare systems around the country, I have been struck by the passion and energy doctors, nurses, pharmacists, and administrators have put into preventing patient harm – driven as much by their moral compass as by the increasingly robust business case for safety.
So, even as we vow to redouble our efforts in the second decade of the patient safety movement (and we must), we should take some pride in the work of the first, work that has unquestionably saved many thousands of lives.
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You rock…keep up the great work.
I agree Lisa. I found this quote in another blog that aptly describes the JCHAO…
“Lately, the JC has devolved into something akin to an aging toll booth operator who lazily takes a token from every motorist who wishes to pass, with nary a glance to see if the vehicle they’re driving is actually road worthy.” this is from the HealthCare PSI Blog.
Ain’t it the truth.
Kathy, whether they’re accredited by JCAHO or not is irrelevant. Having JCAHO accrediation is like saying they’re listed in the phonebook.
JCAHO doesn’t accredit all hospitals. I also contacted them and the small Maine hospital my father was infected in and died as a result was not JCAHO acredited. So, obviously they were no help to me. The same hospital is now associated with a major medical center here in Maine. I am fully confident they will now be accredited and nothing about any past HAIs or errors will matter one tiny bit. Those failures involved 3 deadly infections in one single month in a 25 bed hospital. And those are only the ones I know of. My father was one of them.
I wrote to JCAHO at least 4 times. I got the same letter back each time. “The hospital’s response, if any, is confidential.” Except the 4th letter said the file is closed. I monitored JCAHO’s website over an approximate 18 month period at least, they never set foot in this facility as a result of my many well-documented violations to their standards. There are many, many similar stories. Here’s an example of a sentinal event at a JCAHO facility, the child died while JCAHO was on-site doing their inspection. They didn’t do anything about it (IE: suspend accrediation status pending investigation). http://www.lewisblackman.net Healthy child slowly bled to death over a 4 day period. Mom kept asking for a doctor, she recognized the symptoms of shock from what she learned in high school first aid. Nurses were too busy polishing doorknobs and hanging decorations in anticipation of their upcoming JCAHO inspection to bother with a child in crisis. This was back when they used to schedule their inspections. By the way this was a healthy child admitted for an elective procedure. If that’s not negligent homicide, I don’t know what is. “A boy scout could have done better” said the local paper. Indeed.
I too have contacted JACHO and asked if I could be of assistance.I’m not sure what they are doing but I found them as nothing more than a sounding Board. Taking on personnel experiences and Archiving them.
They sent their standard letter that the received a reply from the Hospital and that the contents cannot be revealed for my review and /or rebuttal. Actually, Jacho acted in the same manner as the Hospital and the Department of Health. They would not discuss or allow review of the subject matter.
Bev, When I have spoken about arrogance. WE know that some are arrogant but it is the Hospital and the industries cultural Arrogance that is most Frustrating. I do not see Lisa as being arrogant because I have empathy for her experiences. I know some of those experiences and know them to be true.
On the other hand Health Care Workers do not want to focus on the unpleasantness of Staph Infections and Medical error. I don’t know why they fail to recognize the threat? Could it be they are paid the same regardless of outcome? Could it be that re-admissions benefit the Hospital and Death benefits the undertakers union? How narcissistic can a person become in this field of study and still claim to care about Patient Safety?
The most important question is; what do they have to fear to included community members to set patient safety policy? Answer: Health Care cannot Control the outcomes due to career status.
Bev MD, I didn’t blow you off, I’ve responded to all your comments with the reality that is being a patient safety advocate. It’s not arrogant or patronizing, it’s just the facts. You should be alarmed, as a citizen of this country and no doubt a patient yourself one day, that our efforts over the years aren’t bearing results. Instead of wishing us well in our endeavors, why don’t you help us by contacting your legislators and demand mandatory public reporting of medical errors (this includes infections), demand patients be able to access their records without restrictions, demand patients have access to an advocate of their choosing 24/7, demand the CDC and DHHS clean up the industry by regularly investigating complaints, regularly inspecting hc facilities and reporting on same, and in general doing their job, demand national standards for physician and HCW licensing, and demand the FBI investigate JCAHO. There’s a good start we could use the help.
Or, enjoy your golden retirement years in blissful ignorance and we wish for you that you don’t find yourself in our shoes one day. It’s guaranteed you will if the above mentioned items don’t start happening.
Bev M.D.:
We’re not arrogant. We’re angry. We’re angry because we’ve lost our loved ones to a system rife with dysfunction and incompetence. We’ve been denied answers. We’ve been denied justice. We’ve been fighting against arrogance for years. So if you sense cynicism, it’s nothing personal. We just loved and our loved ones lost.
And by the way, while your dispensing advice to us on how we can change the system, what are you doing to change the system now that you are retired? Most of us are not retired. And we spend countless hours and more energy than Con Ed trying to change the system. And without a 401K.
Lisa;
My conclusion from our discussion:
“All patient advocates are arrogant because one of them obviously already has all the answers, patronized me when I tried to be helpful, blew me off when I tried to make suggestions, and generally made it clear she has been at this far longer than I and knew much more than I did.”
Spoken tongue in cheek, of course; but sounds like something one of you might say about docs, huh? Just sayin’. I wish you well in your endeavors; I need comment no more.
Bev MD, we have supported including the pt/family in RCA for years, original credit for this goes to Helen Haskell in South Carolina. When such a suggestion is made to the industry you get a deer-in-the-headlight response…and then they start telling us about our “perspective” (it’s different) and we (pt/family) don’t understand how “complicated” healthcare is. Been there, done that, still doing it.
JCAHO…I appreciate your suggestions but honey, please, don’t get me started on the Joint Omission, their hands are covered in blood and the FBI needs to start throwing JCAHO executives past and present in prison.
#2 is also a good suggestion, I think we have all at one point or another spoken at medical schools. Trying to get the cirriculum changed is an ongoing battle as well. Been there, done that, still doing it.
Thanks
My involvment in and education re patient safety ended when I retired in 2003, so I get the increasing impression you all know more than I do. However, here’s a couple ideas, building on your comments and the quotes from Drs. Berwick and Cassel:
1. Use your joint clout to try to get the Joint Commission to require patient/family input in the process of root cause analysis, which as you know is the formal process where a hospital investigates a sentinel event or near-miss. Not that you should sit in on the whole process; the legal aspects would scare them away. But that, as well as gathering input from the providers and staff members involved in the event, the RCA team is required to interview the patient or family member for their input and perception of the event.
2. Try to pressure the Association of American Medical Colleges (http://www.aamc.org/) to include in their undergraduate curricula (e.g. at the medical student level) formal education on systems thinking, teamwork on how to reduce errors, root cause analysis process, etc. This could start with aksing to give a guest lecture on a sentinel event and how it affected you as the patient or family member. I can promise you the medical students would be riveted – I still remember every patient who came to our lectures in physical diagnosis, etc. and told us how their disease had affected them. They are at least thinking about this on the graduate level (http://journals.lww.com/academicmedicine/pages/default.aspx), but I think that’s too late in their training.
Again, you all may be way ahead of me, but you have the power of a critical mass and passion.
There’s an advocate on the east coast who was told by a hospital CEO “We don’t want to see your faces.” Because we’re the faces of their failures.
Another advocate encountered the CEO of her subject hospital at an event recently. The last time she saw this CEO was at the settlement conference years earlier regarding the harm to her son. She told me it took everything she had in her to approach this CEO and say hello. The CEO had no idea who she was. The most devastating event in advocate’s life happened in this facility, changed her life, and sparked a crusade that’s going on a decade. It was just another day at work, and totally forgettable, to the CEO. Since that time advocate has tried to engage the CEO in working jointly on patient safety, even tried to negotiate a joint presentation at an upcoming event the advocate had, hospital said thanks but no thanks. Advocate used the media to put public pressure on facility, as a result of the Modern Healthcare article, it was the first time in 10 years the hospital had anything to say other than “no comment.” It’s quite a lot of shenanigans advocate has had to go through, and is still going through, to try and partner with hospital leadership. Her name is Sue Sheridan.
Memorial Hermann in here in Houston continues to ignore me, the executive leadership all know who I am. Dr. Bev, The Hospitalist article made the rounds with the patient safety advocates, many of us wrote letters to the editor and I believe they were published online or will be in a future edition. I’ll check on that.
Dr Bev,
I agree with both of the doctors quoted. Hospital Leadership and Medical Educators just don’t “get it”. Maybe they need to recruit real life victims and/or families of victims to educate these people. They and some other professionals have no idea how their errors/neglect impact patients and their families. It is so simple for people who sit in nice plush offices or professors who no longer interact with (or even touch) patients to just slide over the cause and impact of adverse results. Those results I am referring to are death or long term disability.
Somebody needs to bust the bubble these people live in.
I forgot to source my excerpted quote above:
“The Hospitalist”, Nov 2009. http://www.the-hospitalist.org
Here’s an interesting quote from a 10 year followup interview with 2 of the IOM’s original committee members issuing the report 10 years ago:
“Q: In retrospect, what was missed in the report?
Dr. Berwick: If we missed any boat in our analysis, the idea of “no blame” is not meant to relieve everyone of responsibility for medical errors, but to relocate responsibility for safety in the offices and work of leaders of healthcare institutions. The finger points to the executive suite. There’s more and more evidence that safety does not improve without the clear commitment of leaders.
Dr. Cassel: When we think about how we train doctors, which I spend a lot of time doing, they just aren’t trained to think of root-cause analysis or how to work in teams to reduce errors. That needs to change. ABIM’s new pathway for hospitalists, which will be rolled out in another year or so (see “A-Plus Achievement,” p. 1), treats questions of how … to identify patient-safety issues as core knowledge.”
I think both of these answers are right – except Dr. Cassel’s efforts need to be refocused on medical schools rather than just hospitalists. I have heard from someone in the industry that medical schools just are not getting it in terms of this training being a necessary part of their curriculum.
Don’t ask me Lisa. I’m Conflicted. The absence of common sense and due diligence seems to be contrary to the mission of this Profession. If your civil and respectful the entire profession blows your concerns off as some fiction novel. While if you take the approach of getting into their Faces and spouting the Obvious,the Profession seems to treat you as some lunatic. Either way they are not going to listen.
Our Federal Government bribes these professionals to achieve realistic goals and they use grants to woe investors.
Strangely enough, these professionals are not in the least, concerned about their own welfare. Or even if they are the vehicle that spreads Hospital Infections to the patients.
I guess this is considered Defensive Medicine. If no one knows than the reality is, no one can be held accountable.If someone were to weaponize staph infections that targeted Health Care Workers. Then they would be pushing for immediate change.
We all know there are solid evidence based research and proven track records to support ADI precautions. I don’t know why it is so difficult for the industry to accept the obvious? I guess they have spent to much time sitting on their brains.Suffocation does kill brain cells!
While it may feel good to focus on certain areas of “progress” in patient safety, anything that does not transmit down to immediate improvement in the way patients are treated and ensures their safety is little more than window dressing. I can’t think of any business in this country that is given such an outrageous pass on abuses, negligence and incompetence the way healthcare is. Having the foxes rate the fox with preformance score cards and the like is just another way of doing anything but the right thing.
These are literally life and death matters for patients and nothing short of immediate action is appropriate.
There is no substitute for real accountability.
Gary, I’m not sure why you even gave that advice (don’t be angry) the time of day. It’s high time this angry mob got out their pitchforks, damn your studies and data. Bev MD, you should watch this webcast and listen to the journalists speak about how difficult-to-impossible getting data on patient safety matters is: http://mindmedia.vo.llnwd.net/o21/kaiser/091117/f.htm
Also, one of CNN’s 5 tips on not falling victim to medical errors is to “be impolite” http://www.cnn.com/2009/HEALTH/11/11/hospital.mistakes/
And finally, if you went through the same trials and tribulations with your 88 year old mother, you would have found quick results once you started throwing some flames of anger. Why are our standards so low in healthcare? Why is that? Everywhere else in society we value human life…as long as it’s not receiving medical treatment, that is. Why is that?
Hi Bev,
Thank you for your thoughts on this Matter. Still,The Grief process is unpredictable and displays a variety of emotions. I can honestly say that I have on numerous occasions made concerted efforts in a pleasant tone and manner and it has fallen on death Ears.I have for the last two years forwarded new Data to the State Legislature and the Tennessee Department of Health on a weekly bases.Simply,to keep it from being out of mind and out of sight.
Doctors seldom actively listen to Patients and it is the arrogance of the profession that places patients at greater risk.It is the Culture much more than the person that can jeopardize a patients Health.I also wonder why some Long Term Doctors,who have the GOD Syndrome are not required to have a psychological review to see if they are fit for duty.
On the subject of Credibility. Its Obvious that the profession relies overwhelmingly on Data. Something that can appear objective can be subjective by the provider of the study. If a Pharmaceutical wanted to promote a new product and slants its findings to back its product. How credible is that report. Their have also been findings that are contrary to other articles on the same subject. How credible is that data?
“I am simply pointing out that the minute the anger and flame-throwing surfaces, you completely negate your credibility with anyone in a hospital or doctor’s office, and probably in your congressman’s office too.”
How do you explain the Political Parties that has been Catering to the Far Right?
What I’m getting to is the fact that data can easily by manipulated to support any argument. The Problem from a non Medical student point of view.I do not have access to the proprietary studies of this profession.
Being Civil and failing to express ones self in a stern and unyielding manner . Often times fails to obtain results. For example: My sister has a pinched nerve in the back of the neck. She would follow the suggestions of the Doctor,go to therapy etc; without relief. I told her to be firm and not to take no for an answer and get a referral to a surgeon. She got her referral!
Arrogance is a wall that limits communication,forms judgments founded or unfounded, and is a precursor to a closed mind set. It is that mindset that makes the Concerns of Infections such a Hard sell from the patients prospective. They (the Patients)are the ones bearing the burdens of medical Errors and Infections. By doing nothing makes ignoring it blissful as they have No idea where it came from or how it happened.
We can’t simply wait for the profession to get its house in order. After all they have been chasing the profit lines for to long.We will change the system one patient at a time and make all aware of the unforeseen cost of Hospitalization.
I can assure Dr Bev that my fellow advocates and I went to our legislators on both the State and Federal levels, prepared, informed and angry *justifiably so). The anger for the loss of our loved ones because of negligence and inadequate care, fired our passion to actually do something about it. None of us will ever get our loved ones back. But, we can use our anger, our grief and our knowledge to fire up a prevention storm in our states and country and to help others to avoid the same horrible fate.
Generalities won’t work, I agree, but when we have the facts that are available about medical errors and preventable infections, a little anger-fired passion never hurts. In fact, a substantial number of the representatives I have spoken with had some pretty impressive horror stories of their own that made them angry.
Hi Gary;
I am happy to be the lightning rod for physicians since I am retired and worked in a laboratory anyway. So you see, I was on the other end of the MRSA issue. I completely understand your anger and have experienced it myself on other issues (medical records, lack of communication, lack of thoroughness) on behalf of my 88 year old mother and other relatives completely ill-served by our health care “system”. I am simply pointing out that the minute the anger and flame-throwing surfaces, you completely negate your credibility with anyone in a hospital or doctor’s office, and probably in your congressman’s office too. This may be unfair, but it is reality. If you want to have an impact, cite data and studies and say “this is unacceptable”, rather than “all doctors (substitute whatever other provider you like) are arrogant”, etc. etc.
It’s not what you are saying, it’s how you are saying it which will deny you the impact you desire and deserve.
Dear BEV Md.
I agree with Kathy on the fact that this Conversation would be unnecessary if Hospitals did their part.I also Agree with Lisa that these infections are not intentional and we have some good professionals doing the best they can.
Its been over two years since my mother had died from contributing factors from MRSA and the absence of ADI. I have gotten over my anger a couple of months ago but I have not given up for my passion to spread the news of the hidden Dangers of Hospitals,Out Patient,Long term and nursing home Care.
Did you know that arrogance kills patients and ignorance is Bliss? My father who lost his wife was told M(e)RSA was nothing to be concerned with; siting the medical journal. Actually, arguing with a 81 year old man, (who just loss his wife from complications with MRSA such as sepsis) as if he is a stupid, ignorant, commoner. Such arrogance and no- it- all attitudes is what Kills Patients.Of Course, to Claim Ignorance is bliss and forgoes any accountability.
Food and Water Watch tracks several studies on MRSA and antibiotic resistance in animals. As you know most studies are proprietary and are not publicly shared.For the same reasons that the medical profession chooses to hide their study outcomes.
In the presence of ever increasing evidence based studies on this subject. It is most alarming when arrogance and apathy seems to trump common sense life saving practices.If the Medical Professions fail to act in the protection of their patients from preventable infections and Medical Error. Than please don’t expect me to back off anytime soon.
These stats that you refer to are severely flawed and out dated.I for one can tell you that my mothers bout with MRSA was Not counted in Tennessee. As I followed Up with the State Department of Health and Vital Statistics.
It good that you question data ,but remember its not the Holy Grail.I can not send you any data about anti biotic resistance in animals with out you being suspect of my motives. So I would suggest you do the research yourself and report back on your findings.
We must see the entire picture and not box ourselves into a repeating thought process that fails to recognize a grander theme.
Bev MD
My father was in the hospital the entire 12 day incubation period of his MRSA. He arrived on his first admission with clear lungs and normal WBCs, no fever and no sign of MRSA pneumonia. He was discharged after 12 days and then he was home 1.5 days when he collapsed with his infection. There is absolutely no doubt he was infected while hospitalized…absolutely none. Yet you’d like to say “we dont’ know the facts”. I know the facts and the doctors who treated him for his MRSA know the facts. They told me and my family that he contracted MRSA in the hospital.
Please don’t assume that we advocates and activists are liars or dummies….we know our facts and we get them straight.
And about anger….I couldn’t possibly be any more angry about my fathers infection. And you would be too if it happened to your father, mother, child, sibling, etc.
Data…what a joke. Many hospitals fudge data or they don’t release any. MRSA data is the best kept secret in the USA.
I used my anger (not data, because there isn’t any available to the public) to get a law passed in the State of Maine to screen all high risk patients. The hospitals have fought it tooth and nail, but I fought back. With this screening, hospitals cannot say that “the patient brought the infection in with them, or they were likely infected when they came in, or some visitor infected them, or any of the other lame statements that many victims or their survivors have heard repeatedly. If one is MRSA negative on admission and becomes positive while hospitalized..after 48 hours in hospital….it is hospital acquired. Seems pretty obvious to me and the CDC agrees. If they are positive, then it makes the hospital aware that the patient is at a huge risk for active MRSA infection and they must take the appropriate steps to prevent it. They must also stop the spread from colonized or infected patients by isolating, using contact precautions and considering decolonization. So, not knowing a patients MRSA status is no longer an “excuse” for hospitals…at least in Maine.
I have listened to docs just like you say the same things over and over defending their facilities saying they are doing the best of everything possible… And like Lisa, I know none of these infections are intentional, BUT
They should have been spending their time working on improved prevention instead of fighting it. That way their MRSA rates would be dropping and there would be no need for this conversation.
Gary, I do not contest your comments, but do you have references supporting your contention that giving antibiotics to feed animals has resulted in the proliferation of CA-MRSA? It would seem logical that is so, but I have learned that what seems logical in medicine is not always true. Like it seemed logical that stenting every clogged coronary artery would improve mortality, but it doesn’t, except for certain subgroups of patients.
Remember, data is king, not anger.
Yes ,I’m aware of Community Acquired MRSA and why do you think that is ? Could it be the abuse of Anti-biotics in agriculture? 23 Million Tons of antibiotics are used each year on Healthy Animals because of overcrowded and unsanitary Conditions.Eight(8) times that is used in Humans in a Given Year.In just 30 months of a cows life before slaughter.They have been injected with more antibiotics than we receive in our lifetime.
The AMA is very aware of these practices that use antibiotics to accelerated growth of our Chicken, Cows and pork to name a few. Food and Water Watch have released reports that document antibiotic resistances in healthy animals to promote growth. You are what you eat is so true and even though you are the most Health Conscious. The very organizations that are suppose to protect your health are deceiving us regarding what is safe.
Considering all that takes place in Hospitals and even Agriculture. It would seem that Best Practices and Antibiotic Use regardless of industry should be a No Brain er. However, it is often ignored in the interests of profits.
So as long as CA-MRSA and HA-MRSA are largely being Ignored. Please for give me for spreading news of Anti biotic resistance and how to identify and protect yourselves from it.
In the future, I hope Health Care will recognize High Risk Patients and test them for MRSA. Using ADI as a means to address the issue. The VA of all Hospitals are doing a Terrific Job in this Area. The Lab can identify the difference between the two. However, Hospitals do a terrific job covering up Hospital Acquired. So not to risk needless exposure to lawsuites.
Um, I’m not going to get involved in the MRSA fight above, but I assume those involved are aware that there is a strain of MRSA which is community-acquired and that the incidence of this strain is increasing faster than HA-MRSA?
http://www.cdc.gov/ncidod/dhqp/ar_mrsa_ca_clinicians.html
Obviously we have no way of knowing which strain was involved in the cases cited above, but it is simplistic to categorically state that all MRSA cases which first manifest within a hospital are by definition hospital-acquired. A visitor carrying CA-MRSA, for instance, could give it to the patient.
Not being defensive, just trying to keep this discussion factual.
Does anybody know if Rhode Island Hospital uses their checklists? For those who might not know, RIH was recently fined $150k for 5 wrong site surgeries. (not sure why it took 5 events to get action, but anyway…). Patient safety advocates endorse the use of checklists, with respect to wrong site surgeries checklists are 100% effective at preventing a wrong site surgery. So, I’m wondering, does anybody know if RIH used checklists? Because if they did we need to know why the use of checklists failed.
How do I know (that charts in my hospitals are mostly accurate)? Because I know at least a large part of what’s going on with the patient, and what is documented by whom and when.
I’m sorry but this isn’t an answer. The answer is you do not know.
Again, most hospital staff is not interested in harming patients. If that is what you think, I am not sure whether you are in the right field. I never said anybody INTENDED to hurt patients, but it’s happening nonetheless. With great frequency, and as other posters have mentioned here, often times it’s PREVENTABLE. Rbar I don’t believe you have spent much time as a patient in a hospital.
How do I know (that charts in my hospitals are mostly accurate)? Because I know at least a large part of what’s going on with the patient, and what is documented by whom and when. Again, most hospital staff is not interested in harming patients. If that is what you think, I am not sure whether you are in the right field.
Re. physicians protecting each other, it probably still happens … but probably not as often as you suggest. I have seen academic physicians (not “experts from the gutter” as you suggest, although boundaries are blurred here) testifying harsh and unfairly against other physicians. I have seen internal peer review with physicians secondguessing colleagues without mercy. And I have heard many physicians (and patients reporting physicians) speaking in a derogatory fashion about other physicians or aspects of the care they received from other physicians. In other words, there are physician diagreeing in pretty much any kind of scenario, for various motives (money, narcicissm, personal feuds and antipathies). The great cover up you witness and/or perceive is becoming the exception (and that’s a good thing). Or maybe there is tremendous regional variance I am unaware of, but this is something you might want to acknowledge yourself.
“In fact, at least in the various hospitals I worked at (from community to tertiary care), charts are usually very accurate.”
How do you know? What qualifies you to make that statement?
“…medical staff of hospitals or even the entire personel are conspiracies against the patient’s health…” Rbar, you’re giving the industry way too much credit. A conspiracy would require teamwork, collaboration, they’d all have to be working together to pull off a conspiracy against us. They’re not that organized.
You know when I finally saw my husband’s medical records, and started (trying to) read them, I was shocked. Errors, ommissions, even outright lies. My sister, who had been a nurse for over 13 years at that time, was flummoxed as well. I finally asked her, is this what they teach you in nursing school? Be vague and non-specific? Omit important details? Is this what they teach you do to? She said no, quite the opposite, they taught her if it isn’t in the chart, then it didn’t happen. Such as, elevating the head of an intubated, ventilated patient. Something drastic changed in health care since her days in nursing school, I think lawyers took over.
Rbar, you’re mixing scenarios. A expert from the gutter paid to testify at trial is not the same physician or scientist who’s reviewing medical records for scientific studies.
And yes, there is a lot of cronyism going on in health care, doctors do protect each other. You keep going to the court room, I’m not in the court room.
I should have said the survivors of the 19,000 people who die each year from hospital acquired MRSA.
Robert,
I don’t blame anybody for things that my father did to himself. He could have led a healthier life. I do however blame the hospital for an infection that he caught while hospitalized there. I blame the hospital for not addressing 2 other MRSA deaths just prior to my fathers infection. I blame the hospital for inadequate infection control and not even abiding by the soft and lax CDC recommendations for MRSA control after an outbreak.
YOU BET I DO BLAME THE HOSPITAL. They caused his infection and it could have been prevented.
Just out of curiosity…who would you blame…my father??? I dont’ think so. He went into the hospital for a minor ankle fracture and had NO invasive procedures done. Then he ended up dead 3 months later after a great deal of suffering…not from the ankle fracture, but from a hospital acquired infection.
I a totally justified in blaming his hospital and so are the other 19,000 people who die each year from hospital acquired MRSA infections.
Hospital Acquired Staph Infection deaths exceed that of HIV/AIDS in the United States. MRSA accounts for 65% of all Staph Infections. So why is it treated like the Common Cold?
Some 2 million people are disabled by staph infections,losing limbs,jobs and Quality of Life. Why should We Care? Answer: Its PREVENTABLE!!
Who Knows, the next roll of the Ambulance might be your turn to experience the preventable. After all infectious Disease has no Boundaries.I hope none of you have to experience it.
Your selective BINGO quote suggests that physicians do not second guess their fellow physicians. That’s not true as you pointed out yourself.
With regards to the medical records, I am a little bit surprised about your statements, and I did not make the point you tink I made. The study I quoted/pasted does not at all suggest that charts are factually inaccurate, but that complex medical care is very often hard to consistently rate as appropriate or inappropriate.
In fact, at least in the various hospitals I worked at (from community to tertiary care), charts are usually very accurate. How would falsifying medical documentation work anyway? If someone does not document anything about an event or encounter, it will usually backfire (failure to diagnose or to intervene are common causes for malpratice suits) as it creates the appearances of idleness/negligence for the person failing to document. If someone documents falsehoods (which BTW only “makes sense” for the writer if a serious mistake is known or suspected, but not prospectively, while the mistake is done), there is a high chance of being contradicted by other staff/witnesses. If you talking about changing the chart in retrospect, that may happen rarely and is often discovered, bringing the changer into serious trouble with a potential jury.
IMHO, the IoM study as well as some safety advocates create paranoia that the medical staff of hospitals or even the entire personel are conspiracies against the patient’s health (or at least against any attempt to clarify mistakes and improve outcomes). This might very well be the case sometimes and you may have witnessed this (and this of course should not be tolerated and I think is getting more rare every year), but that is not the rule and not the assumption you should make when you enter a hospital.
What Part of Preventable do you not understand;Robert.Its not the Blame game. However, it is the ability to recognize a problem and address that Problem.Apparently, you have not experienced staph infections of family and friends close up.So it is described as blaming without changing the Direction of the Spread of Infectious Disease.
The Facts are these people want to bring forth the needed changes to protect others from experiencing needless loss of life. By the way that includes you!
Across the country, We have had spotty programs in the reduction of Preventable Disease. Some have made tremendous strides and others have done little to address Hospital Acquired Staph Infections. Those who have ignored best practices have the highest incidence of death and disability.
The Health industry has for the most part snub the HA-MRSA and other staph Infections as Part of Doing Business.However those who have taken on ADI guidelines have made impressive gains. In the absence of sound practices by these institutions. It is every citizens duty to spread the Knowledge of Hospital Acquired Infections and protect themselves from potentially deadly outcomes.
I hope that you supply your patients with hand sanitizer to limit the spread of MRSA.
Rbar, with regard to your other question, physicians testifying unfairly against other physicians. I don’t know how to answer that question directly other than to say based on my knowledge of the legal system, anybody with a checkbook can find any so-called expert right out of the gutter and get them to say, under oath, whatever the writer of the check wants them to say. I’m sure there are physicians who give expert testimony against other physicians, what’s your point? It’s not up to you or me to decide whether it’s fair or not, that’s what judges and juries are for.
The insurance company that sued my husband got one of those out-of-the-gutter “expert” doctors to testify. He never laid eyes on my husband, was never involved in his case, and testified over the phone from 300 miles away. What’s your point, Rbar?
Rbar, I did read your entire post, I am not going to read it again now but you mentioned charts not being reliable sources of information more than once and I don’t know why you would call this selective reading or whatever else you’re diagnosing me with. Now you’re getting to the root of the problem, enough said, medical records are not reliable or accurate sources of information. It was a good point and whether or not you wanted to make it, I’m glad you did.
Most of the posts here seem to be about finding someone to blame when something bad happens. When I see outpatients with no previous contact with the medical system who present with life-threatening MRSA infections, whom should I blame? Thanks for the help!