OP-ED

Two Kidneys and 100,000 Lives

This story about a kidney transplant mix-up in California is bound to get lots of coverage. It is these extraordinary cases that get public attention. I am sure it will lead to a whole new set of national rules designed to keep such a thing from happening.

Of course, such rules already exist, and it was likely a lapse in them that led to this result.

Nonetheless, we will “bolt on” a new set of requirements that, in themselves, will likely create the possibility for yet a new form of error to occur.

This kind of coverage and response is a spin-off from the “rule of rescue” that dominates decisions about medical treatment. We find the one-off, extreme case and devote excessive energy to solving it. In the meantime, we let go untreated the fact that tens of thousands of people are killed and maimed in hospitals every year.

Those numbers are constantly disputed by the profession. To this day, many doctors do not believe the Institute of Medicine’s studies that documented the number of unnecessary deaths per year.

And you never hear anyone talking about this 2010 report by the Office of the Inspector General, which concluded:

An estimated 1.5 percent of Medicare beneficiaries experienced an event that contributed to their deaths, which projects to 15,000 patients in a single month.

As the IOM notes, “Between the health care we have and the care we could have lies not just a gap, but a chasm.”

There is an underlying belief on the part of policy makers and public and private payers that the focus on quality is best addressed through payment reform. Let me state as clearly as I possibly can: That is wrong. It is a classic example of the old expression: “When you have a hammer, everything looks like a nail.” Changes in payment rate structures, penalties for “never events,” and the like can cause some changes to occur. Their main political advantage is that they give the impression of action, and their major financial advantage is a shift in risk from government and private payers to health care providers.But these are gross tools and will have unintended consequences. More importantly, they do not get to the heart of the problem, the manner in which work is organized in the highly complex environment of hospitals and physician practices. This is an environment in which ineffective work-arounds — instead of front-line driven process redesign — are the usual answer to obstacles in patient care.

They do not address the unmet education needs of doctors-in-training, training that is a throw-back to a cottage industry in which each person is expected to be an artist, relying on his or her creativity, intuition, and experience when taking care of a patient. The resulting lack of standardization — the high degree of practice variation — creates an environment that is inimical to process improvement based on scientific methods.

They do not address the documented advantages of engaging patients in the design and delivery of care, nor the power that such engagement brings to both doctors and patients.

Add to this the sociology of dehumanization in medical schools documented by Linda Pololi, and you have a stewpot of well-intentioned people destined to kill and maim others.

It is up to the medical profession, not the politicians or the insurance companies, to change this. First, though, they have to be willing to acknowledge that problems exist, that the current level of harm is not a statistically irreducible amount. The need to put aside the usual responses — “the data are wrong” — “our patients are sicker” — “our care is the best in the country” — and have the intellectual modesty to recognize that the real work has just begun.

To the extent the medical profession continues to abdicate responsibility, the more will step in politicians, regulators, and payers to do it for them. If you are a doctor and already feeling a lack of control over your professional life and your relationship with your patients, just wait.

I have previously quoted experts on this field, but the most cogent imperative remains the one provided by Ethel Merman:

Now what kind of an attitude is that, ‘these things happen?’ They only happen because this whole country is just full of people who, when these things happen, they just say ‘these things happen,’ and that’s why they happen! We gotta have control of what happens to us.”

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Surgical TowelPreventable Medical ErrorsDoc Bbev M.D.Margalit Gur-Arie Recent comment authors
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Surgical Towel
Guest

Incidentally, I like the way you have structured your site, it is super and very easy to follow. I have bookmarked you and will be back regularly. Thank you

Paul Levy
Guest

Cory,

We have now beat this horse to death. The numbers presented are actual numbers. Notice the reduction in mortality, too.

But, I am not going to argue the numbers here. They are not the main point.

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[…] his profile I assumed he was an administrator of a hospital.  You can read the post and comments here. This story is a case of a true medical error. The post generated a lot of comments, most of which […]

cory
Guest
cory

Paul; Sorry – Put simply, I doubt seriously you did dropped the length of stay by simply reducing infections. That certainly could have played a role. No question. But you admitted 1500 more patients in 2009 than in 2005. Four more patients every day? You can tell me seriously that that was primarily the result of reducing infections? you can seriously tell me that admission policy/case-mix severity had nothing to do with that? How could you possibly know that without more info? Did you measure it? How? You didn’t build more ICU beds? you didn’t change post-op or preop policies?… Read more »

bev M.D.
Guest
bev M.D.

Doc B; I implore you to read the book about Virginia Mason – its CEO is a physician and it addresses many of the fears you express. This is NOT about cookbook medicine at all. What you are seeing on your rounds is a mindless bastardization of the idea by the uneducated. That is why we must take charge of it and lead. And btw, 95% of the errors I chased were human, not equipment related. Many on the part of nursing or lab/nursing interaction. And in signing out surgical path slides I, too, was hostage to process errors, such… Read more »

Doc B
Guest

bev M.D., The excerpt is correct.; “process redesign” is the answer. You’re arguing with the wrong person. I stated earlier that I do not tolerate errors. In your field, laboratory, with technical equipment and computer automation, your tolerance for error should be zero and that still is not attainable. Unfortunately, patients are human beings, not machines to be programmed or calibrated. There is no manual or “standard” for patients and therefore patient care. If patients were as your labaoratory equipment, we could simply read the manual to derive a correct result, or troubleshoot a specific problem. Diagnosis and treatment are… Read more »

Paul Levy
Guest

Cory and others, Let me switch gears from the “data wars” and put it this way. This is about motivation and choosing to act. One of our bright young doctors put it this way: “I spent a tremendous amount of time thinking about what motivated us (“us,” here, being ICU providers) to work on a problem in a way that led to sustainable change. I came to the conclusion that – as a quality and safety professional – about 90% of my work was convincing people that there was a problem that was (a) common, (b) lethal, (c) expensive, and… Read more »

Paul Levy
Guest

Oh, Cory, you are so wrong on so many fronts and are muddling cause and effect In short, the length of stay dropped because we reduced the number of infections in the ICU, not because of a case-mix change. But, look, the whole point of this is that there are ways to improve the work flow in hospitals, to reduce variation, to eliminate harm. Your quibbling — and I will call it that — about how to count the number of cases is not doing anything to help support the proposition that the profession needs to get to work on… Read more »

cory
Guest
cory

Bev: My point is you have to understand the numbers. Without that, you can not understand the effects of the interventions. And I think I can illustrate this using Dr. Levy’s numbers- I want to show you this is not semantics, nor quibbling over minutiae. Look at Dr. Levy’s graph- with that large patient base, I am going to assume this represents a combination of several multidisciplinary ICUs, probably in a university medical center. We are concerned with # of deaths prevented OK- # of deaths = (mortality rate) (number of patients) With me, so far? I am going to… Read more »

Paul Levy
Guest

Other data are posted at http://www.bidmc.org that show the reduction in central line infections rate from about 4 per thousand patient days to almost zero. Pronovost showed the same in Michigan: http://runningahospital.blogspot.com/2011/02/our-patients-are-sicker.html These are real numbers based on real changes in the manner in which care was delivered.

Paul Levy
Guest

Margalit,

This had nothing, nothing, to do with technologies, drugs, and the like. It all had to do with revising the way work was done in the hospital to reduce variation and to assiduously carry out the protocols for reducing central line infections and VAP. See, here, for example about compliance with the VAP bundle: http://runningahospital.blogspot.com/2007/09/teamworks-wins-against-vap.html

bev M.D.
Guest
bev M.D.

Doc B: I suggest you read a book about Virginia Mason hospital in Seattle http://www.amazon.com/Transforming-Health-Care-Virginia-Experience/dp/1563273756 You have to get past the misleading title to the central point which is embodied in Mr. Levy’s quote: ,,,,, More importantly, they do not get to the heart of the problem, the manner in which work is organized in the highly complex environment of hospitals and physician practices. This is an environment in which ineffective work-arounds — instead of front-line driven process redesign — are the usual answer to obstacles in patient care It’s precisely that concentration on ‘fixing’ errors (the rescue approach he… Read more »

bev M.D.
Guest
bev M.D.

OK, cory but tell me – all the effort you put into documenting your comment up there would have been better used in process improvement such as at Virginia Mason to just fix the problem – which we know exists, however we want to quantify it.

So what exactly is your point, other than that the data is wrong? What action items are you suggesting?

Margalit Gur-Arie
Guest

Sorry for the lay question, but in those graphs, what part of the improvement in outcomes is attributable to process improvement and what part is attributable to advances in technology, drugs, devices, therapies, etc. which must have also occurred somewhere between 2005 and 2009? Can we somehow isolate the effects?

Paul Levy
Guest

Well, now, that comment seems like an orphan because a longer one that i left has yest to be published. Trying again here: Cory and Doc B,

Please look here to see and example of VAPs avoided and decrease in hospital mortality rate at BIDMC. Likewise, other data are posted at http://www.bidmc.org that show the reduction in central line infections rate from about 4 per thousand patient days to almost zero. Pronovost showed the same in Michigan: http://runningahospital.blogspot.com/2011/02/our-patients-are-sicker.html These are real numbers based on real changes in the manner in which care was delivered.