By SAURABH JHA
In 1999, the Institute of Medicine (IOM) in their landmark report – To Err is Human – estimated that the number of deaths from medical errors is 44 ,000 to 98, 000. The report ushered the Quality and Safety Movement, which became a dominant force in all hospitals. Yet the number of deaths from medical errors climbed. It is now touted to be the 3rd leading cause of death. How easy is it to precisely quantify the number of deaths from medical errors? Not many physicians challenged the methodologies of the IOM report. Some feared that they’d be accused of “making excuses for doctors.” Many simply didn’t have a sufficient grip on statistics of measurement sciences. One exception was Rodney Hayward – who was then an early career researcher, a measurement scientist, who studied how sensitive the estimates of medical errors were to a range of assumptions.
Saurabh Jha (aka @RogueRad) speaks with Professor Hayward for the Firing Line Podcast about his research in JAMA published in 2001 – Estimating Hospital Deaths Due to Medical Errors: Preventability Is in the Eye of the Reviewer. It was a landmark publication of the time, and its objective methods have stood the test of time.
Rod Hayward a Professor of Public Health and Internal Medicine at the University of Michigan and Co-Director of the Center for Practice Management and Outcomes Research at the Ann Arbor VA HSR&D. He received his training in health services research as a Robert Wood Johnson Clinical Scholar at UCLA and at the RAND Corporation, Santa Monica. His current and past work includes studies examining measurement of quality, costs and health status, environmental and educational factors affecting physician practice patterns, quality improvement, and physician decision making. His current work focuses on quality measurement and improvement for chronic diseases, such as diabetes, hypertension and heart disease.
Listen to their conversation on Radiology Firing Line Podcast here.
To understand how a landmark new report on diagnostic error breaks the mold, go past the carefully crafted soundbite (“Most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences”) and rummage around the report’s interior.
You can’t get much more medical establishment than the Institute of Medicine (IOM), also called the National Academy of Medicine, author of the just-released Improving Diagnosis in Health Care. Yet in a chapter discussing the role played in diagnostic accuracy by clinician characteristics, there’s a shockingly forthright discussion of the perils of age and arrogance.
“As clinicians age, they tend to have more trouble considering alternatives and switching tasks during the diagnostic process,” the report says. Personality factors can cause errors, too: “Arrogance, for instance, may lead to clinician overconfidence.”
Wow. Sure, both those assertions are extensively footnoted and hedged later with talk of the importance of teams (see below). Still, given the source, this practically qualifies as “trash talking.”
Of course, those quotes didn’t make it into the press release. There, inflammatory language was deliberately avoided so as not to give opponents any easy targets. (Disclosure: I was an advocate of an IOM report on this topic while consulting to an organization that eventually helped fund it. After testifying at the first committee meeting, I had no subsequent involvement.)Continue reading…
Thirteen years ago, in the midst of widespread publicity about anthrax-laden letters poisoning people, emergency room physicians sent a postal worker home with a diagnosis of the flu. He later died from anthrax inhalation.
Fast forward to 2014, with the Ebola outbreak in Liberia dominating healthcare coverage, a man who had just returned from the stricken nation visited an emergency room with symptoms but was not tested for Ebola. He was sent home with antibiotics.
Two days later, he was diagnosed with Ebola. In the intervening days, he potentially exposed family members and many more to the deadly virus. At the hospital where the misdiagnosis occurred, officials acknowledged the doctors had the information about the patient’s recent travel in Liberia but didn’t act on it..
How can this continue to happen? In 2010, the Institute of Medicine (IOM) examined the threat of bioterrorism and infectious disease outbreaks and said the most “crucial step in disease detection is the first one – recognizing that an ill patient has a potentially unusual disease…” But it recognized the potential for misdiagnoses of diseases physicians rarely see – such as Ebola and anthrax poisoning – especially in busy emergency departments where information can get lost or overlooked.
The IOM recommended the use of clinical decision support tools to ensure doctors quickly and accurately detect and diagnose unusual diseases. Four years later, some hospitals have these tools and use them. But most do not, even though they’re readily available, affordable and proven effective.
I am a public health professional, educated at the vaunted Johns Hopkins University Bloomberg School of Hygiene and Public Health. I like guns, and I believe the Second Amendment clearly secures the rights of individuals to own firearms.
You read that correctly. I am a public health professional.
And I like guns.
This make me a heretic in American public health, where embracing firearms and the rights of gun owners is a gross violation of orthodoxy.
As a society, our focus on guns and not gun users derives from the shock of mass killings, such as those in Newtown, CT, Aurora, CO, Virginia Tech, and Norway, which has some of the strictest gun control laws on the planet. Mass killings, however tragic, get distorted by saturation media hysterics and 24-hour political grandstanding. What gun opponents refuse to discuss is the precipitous fall in violent crime and deaths by firearms over the past 20 years, and how it coincides with an equally dramatic increase of guns in circulation in the US.
While that isn’t cause and effect, the association is certainly curious.
In 2013, the Institute of Medicine, at the behest of the Centers for Disease Control, produced a report on firearms violence that has been ignored by the mainstream media. The upshot: defensive use of firearms occurs much more frequently than is recognized, “can be an important crime deterrent,” and unauthorized possession (read: by someone other than the lawful owner) of a firearm is a crucial driver of firearms violence.
That report went away for political reasons. Translation. Nobody wanted to talk about it because it raised more questions than it answered.
“You’ve got to be very careful if you don’t know where you are going because you might not get there.”
– Yogi Berra
“Would you tell me, please, which way I ought to go from here?” said Alice.
“That depends a good deal on where you want to get to,” said the Cat.
“I don’t much care where —” said Alice.
“Then it doesn’t matter which way you go,” said the Cat.
“— so long as I get SOMEWHERE,” Alice added as an explanation.
“Oh, you’re sure to do that,” said the Cat, “if you only walk long enough.”
– Alice’s Adventures in Wonderland
The country is in the midst of an unprecedented transformation of the health care system and may even be at a ‘tipping point’, yet many of us find it astounding that we have no official (or unofficial for that matter) collective vision of where we are headed, thus how the heck do we know if we are on the right path to get there? Given the very high stakes and costs that extend far beyond financial ones, why is it acceptable to not have a future state in mind so that the current state can be quantified and a gap analysis roadmap can be created to address it? Sure, we have the Triple Aim as the overall goal but what are the ‘guardrails’ that help build the road to it?
The truly great news is that we actually have those ‘guardrails’, and in fact have had them for over a dozen years. It is just that most people have not been aware of this hidden time-tested gem, created by incredibly thoughtful health system transformation forefathers and foremothers back in 2001. This visionary team has overwhelmingly been praised for creating the powerful and gutsy call to action in their Crossing the Quality Chasm Institute of Medicine (IOM) report. What many have missed is that in addition to all the highly visible work, the group created a set of 10 key new rules to inform a future state for the health care system (see figure 1).
Figure 1 Source: Institute of Medicine, “Crossing the Quality Chasm,” p. 67, 2001.
Twelve years later, the chart in Figure 1 strikes many of us in two powerful ways: 1) How the ‘New Rule’ column has stood the test of time for the vast majority of its intended direction and spirit, and 2) how sad and disappointing that many of the 2001 ‘Current Approach’ column items are still entrenched even today.
The Leapfrog Group has just released its latest report grading the safety of hundreds of individual hospitals, but the real news isn’t the“incremental progress.” It’s how a group started by some of the most powerful corporations in America has quietly devolved into just one more organization hoping press releases produce change.
Amid the current enthusiasm for “value-based purchasing” by employers and possible privatization of Medicare, it is worth examining why Leapfrog’s initial notion that corporations would spearhead a crackdown on crummy care failed and what we can learn from that publicly unacknowledged failure.
Leapfrog was launched with the hoopla of a high-powered initiative. A widely publicized 1999 report by the Institute of Medicine declared that up to 98,000 patients die every year in hospitals from preventable errors and more than one million are injured. In November, 2000, the newly formed Leapfrog Group announced three targeted “leaps” in patient safety that promised to save some 58,000 lives, prevent a half million medication errors and (in calculations that came later) save billions of dollars.
“The number of tragic deaths brought about by preventable medical errors is too striking for those of us in the business community to ignore,” declared Lewis Campbell, chairman and CEO of Textron TXT -0.29%, at the group’s launch.
Campbell was head of a health care task force of the Business Roundtable, an elite group of corporate leaders that sponsored Leapfrog. Wielding the power of the checkbook to enforce “aggressive but feasible target dates” was “a straightforward business approach to tackling a complex problem,” Campbell explained.
“We spend far more on health care than other peer countries yet have worse outcomes. Why is U.S. health care so expensive?” I’m sure you’ve encountered similar statements, maybe even expressed it yourself. It occurs often, including by knowledgeable people and health-related institutions. However, it’s a fallacy because it confuses health care with population health.
Health care is a proper subset of population health. For example, longevity is determined by more than just health care. Using a specific recent estimate (Appendix Exhibit A6 – gated), an average 20-year old U.S. white male who did not graduate high school will live 10.5 fewer years than a similar man with a college degree. That’s over ten years of life related to educational attainment. Sure, there are many reasons for the difference, and health care or the lack of it is only one of them.
Employer outlays for workers’ health insurance slowed from a 9 percent jump last year to less than half that — 4 percent — this year, according to a new survey from the Kaiser Foundation. Good news?
Our political class believes it is. The Obama administration attributes the drop to the new Affordable Care Act, which, among other things, gives states funding to review insurance rate increases.
Republicans agree it’s good news but blame Obamacare for the fact that employer health-care costs continue to rise faster than inflation. “The new mandates contained in the health care law are significantly increasing the cost of insurance” says Wyoming senator Mike Enzi, top Republican on the Senate health committee.
But both sides ignore one big reason for the drop: Employers are shifting healthcare costs to their workers. (The survey shows workers contributing an average of $4,316 toward the cost of family health plans this year, up from $4,129 last year. Many are receiving little or no employer-provided coverage at all.)
Score another win for American corporations — whose profits continue to be robust despite the anemic recovery — and another loss for American workers.
Those profits aren’t due to a surge in sales. Exports are down (Europeans, Japanese, and Chinese are all pulling in their belts) and American consumers don’t have the dough to buy more.
Dr. Mark Schuster is the William Berenberg Professor of Pediatrics at Harvard Medical School and Chief of General Pediatrics at Children’s Hospital Boston. This essay is based on a speech he gave the featured speaker at the Children’s Hospital Boston GLBT & Friends Celebration in June, 2010.
The first time I stood before a large audience to speak was when I was 13 years old. It was at my Bar Mitzvah. I walked up to the podium, looked out over the sea of faces, and thought to myself, I am a homosexual standing in front of all of these people. And I wondered what would happen if I told them.
That was in 1972, and even mentioning the word homosexual, unless paired with an expletive or derogatory adjective, would have been unacceptable at my synagogue. It would have been unacceptable in my home, my school, or any place I knew. I could not have conceived of telling my doctor. I assumed that I would never say out loud that I am a homosexual. The idea that I would someday be able to stand in an auditorium, stand anywhere, just a few miles from where I live with my husband, our two sons, and our dog, with everything but the white picket fence, was not something I could imagine.
Today I stand on a different stage. The Children’s Hospital Boston GLBT and Friends group asked me to share my story as part of its celebration day. How I got here, what I learned along the way, especially at Children’s, and how the world changed — these are what I will talk about.
A decade after I considered turning my Bar Mitzvah into a public confessional, I entered medical school at Harvard. Some students had started a gay group the year before. They had scoped out the territory, searched for role models, and come up nearly empty. In a creaky old closet, tucked way in the back, they found a world-renowned senior physician at Children’s. He advised against starting the group, offering that it was much better to be secretive about being gay so that no one would bother you. I’ve heard that same advice many times from men and women from earlier generations who had fewer options in their day.
A recent front-page article  in the New York Times conveyed grim news about patient safety. The first large-scale study  of hospital safety in a decade concluded that care has not gotten significantly safer since the Institute of Medicine’s 1999 estimate  of up to 98,000 preventable deaths and 1 million preventable injuries annually.
What for me struck a particularly jarring note was not just the absence of improvement, but the reluctance of the health care leaders interviewed to speak candidly about why progress has been so slow. Instead, they offered nostrums about the need to “do more” or opined that “openness” or better “coordination” would somehow turn the tide.
But tucked in the actual study’s conclusions section, between bland boilerplate about “further study” and a “refocusing of resources,” some carefully worded candor cautiously peeked through: “[T]he absence of large-scale improvement is not evidence that current efforts to improve safety are futile,” wrote Christopher Landrigan and colleagues in the Nov. 25 New England Journal of Medicine. “On the contrary, data have shown that focused efforts to reduce discrete harms, such as nosocomial infections and surgical complications, can significantly improve safety.”
In plain language, we know how to prevent many of these patient deaths, but we don’t. That makes, “Why?” a lot tougher question.