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Tag: Patient Safety

When Medical Error Becomes Personal, Activism Becomes Painful

BY MICHAEL MILLENSON

In the mid-1990s, researching a book about the quality of medical care, I discovered how the profession had for years been ignoring evidence about the appalling death toll from preventable medical error. Though I’d never myself experienced an error, I became an activist.

Recently, however, a relative was a victim, and the frustrating persistence of error became personally painful.

Thanks to my relative being acutely aware of the need to be alert (and a bit of luck), no harm was caused by what could have been a serious medication mistake. That was the good news. The bad news is that even Famous Name Hospitals, like the one where my relative was treated, are rarely doing everything possible to forestall the impact of inevitable human fallibility.

September 17 was World Patient Safety Day, and the theme for the next 12 months is “Medication Without Harm.” That makes this an opportune time to examine more closely what the profession euphemistically calls a “medication misadventure.”

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Super Bowl Sanitation: “Washed Up” Giants Outpoint Docs

Is the New York Giants bathroom more sanitary than your hospital room? Could be. And that player cleanliness may even have helped send the team to the Super Bowl.

Freakonomics co-author and self-confessed germophobe Stephen Dubner, working on a Football Freakonomics segment for the National Football League, noticed that every urinal in the football Giants’ bathroom had a plastic pump bottle of hand sanitizer perched on top – a phenomenon he promptly documented photographically.

Health care-associated infections cause more than 98,000 patient deaths every year. Yet as I’ve noted previously, the guy who just used the toilet at the train station is way more likely to have clean hands than the guy walking up to your bed – or into the operating room – at the local hospital. That’s based on my comparing hospital sanitation with the results of a surreptitious survey by researchers from Harris Interactive of more than 6,000 adults using restrooms at six high-volume sites across the country.

At New York City’s Grand Central Station and Penn Station, only 80 percent of men and women washed up. However, even Atlanta’s Turner Field, where just 65 percent of men washed their hands, looked positively sterile compared to hospitals. The Centers for Disease Control and Prevention found that baseline compliance for hand hygiene was just 26 percent in intensive care units and 36 percent in non-ICUs.

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Health in 2 Point 00, Episode 44

Lotta $$ flowing around health tech services this week. Jessica DaMassa asks me about Alphabet/Google putting $375m into Oscar, Best Buy $800m for GreatCall, no money for med school at NYU & pain for patients in a Netflix movie. All in Health in 2 point 00 minutes!–Matthew Holt

A Policy Agenda to Address New Unintended Adverse Consequences of EHRs

flying cadeuciiIn large part due to the $35 billion, Health Information Technology for Economic and Clinical Health (HITECH) Act incentives more than 80% of acute care hospitals now use EHRs, from under 10% just 7 years ago. Despite considerable progress, we have not achieved all that was originally envisioned from this transformation and there have been numerous unexpected adverse consequences (UACs), i.e. unpredictable, emergent problems associated with health IT implementation, use and maintenance. In 2006, we described a set of UACs associated with use of computer-based provider order entry (CPOE) (see Table 1).  Many of these originally identified UACs have not been completely addressed or alleviated, and some have evolved over time (e.g., more/new work, overdependence on technology, and workflow issues).  Additionally, new UACs not just related to CPOE but to all aspects of EHR use have emerged over the last decade.  We describe six new categories of UACs in this blog and then conclude with three concrete policy recommendations to achieve the promised, transformative effects of health IT. 

1. Complete clinical information unavailable at the point of care

Adoption of EHRs was supposed to stimulate a tremendous increase in availability of patients’ clinical data, anytime, anywhere. This ubiquitous increase in data availability depended heavily on the assumption that once clinical data were routinely maintained in a computable format, they could seamlessly be transmitted, integrated, and displayed between health care systems’ EHRs, regardless of differences in the developer of the EHR. However, complete clinical information on all patients is not yet available everywhere it is needed.

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A New Federal Agency to Oversee Patient Safety?

flying cadeuciiPatient safety should be a major priority for the United States, and that requires designating a centralized entity or coordinating body to oversee efforts to ensure it. Such centralized oversight is one of the key recommendations of “Free from Harm,” a report published in December by the National Patient Safety Foundation. The report highlights the need to create a safety culture, since preventable medical errors in hospitals are estimated to result in as many as 440,000 deaths annually. That would make it the third leading cause of death – after heart disease and cancer.

A new report by the U.S. Government Accounting Office illuminates the challenges that hospitals face in implementing evidence-based safety practices. One of those challenges – determining which patient safety practices should be implemented – underscores the need for a coordinating entity and resource. The report states: “(Hospital) Officials noted that they face challenges identifying which evidence-based patient safety practices should be implemented in their own hospitals, such as when only limited evidence exists on which practices are effective. For example, officials from one hospital told GAO that the hospital tried several different practices in an effort to reduce patient falls without knowing which, if any, would prove effective.”

What’s more, preventing medical errors in hospitals is only part of the national challenge, as most health care is provided outside of hospital settings: in physicians’ offices and clinics; in outpatient surgical, medical, and imaging centers; and, in long-term, hospice, and home-care settings, among others. There are about 1 billion ambulatory visits each year in the United States, compared to 35 million hospital admissions. Those ambulatory settings are subject to medical errors as well. According to studies cited in “Free from Harm,” more than half of annual, paid, medical malpractice claims were for events in the outpatient setting.

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On the Preventability of Lethal Errors: A Response to Dr. Koka

In my opinion, the title of Dr. Koka’s post (“Very Bad Numbers“) is far too inflammatory for a subject that needs to be taken seriously. Dr. Koka’s summary of the approach I took in my JPS study is a reasonable summary, minus a few key points. Preventability of lethal errors is the problematic issue. The nine authors of the Classen paper did postulate that virtually all serious adverse events they found are preventable; I did not pull this out of the air. Preventability is a highly subjective area. A few years ago everyone assumed that hospital acquired infections were simply the cost of doing business. Now we know that the majority of infections can be prevented. The major difference Dr. Kota and I have is that he wants to rely exclusively on the Landrigan study, which is an excellent and large study, but it is not representative of the nation. It represented hospitals in North Carolina. That state was chosen because it was much more aggressive in efforts to reduce medical harm than the average state in the nation. The OIG study (2010) was in fact an attempt to be representative of the Medicare population across the country, but it is just Medicare beneficiaries. As I noted in my paper, none of the four studies can stand alone, not even the Landrigan paper.Continue reading…

Potential Bias in U.S. News Patient Safety Scores

flying cadeuciiHospitals can get overwhelmed by the array of ratings, rankings and scorecards that gauge the quality of care that they provide. Yet when those reports come out, we still scrutinize them, seeking to understand how to improve. This work is only worthwhile, of course, when these rankings are based on valid measures.

Certainly, few rankings receive as much attention as U.S. News & World Report’s annual Best Hospitals list. This year, as we pored over the data, we made a startling discovery: As a whole, Maryland hospitals performed significantly worse on a patient safety metric that counts toward 10 percent of a hospital’s overall score. Just three percent of the state’s hospitals received the highest U.S. News score in patient safety — 5 out of 5 — compared to 12 percent of the remaining U.S. hospitals. Similarly, nearly 68 percent of Maryland hospitals, including The Johns Hopkins Hospital, received the worst possible mark — 1 out of 5 — while nationally just 21 percent did. This had been a trend for a few years.

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The Dangerous Patient Safety Delusions of Eminence-Based Medicine

The eminent physicians Martin Samuels and Nortin Hadler have piled onto the patient safety movement, wielding a deft verbal knife along with a questionable command of the facts.

They are the defenders of the “nobility” of medicine against the algorithm-driven “fellow travelers” of the safety movement. On the one side, apparatchiks; on the other, Captain America.

They are the fierce guardians of physician autonomy, albeit mostly against imaginary initiatives to turn doctors into automatons. By sounding a shrill alarm about straw men, however, they duck any need to define appropriate physician accountability.

Finally, as befits nobility, they condescend to their inferiors. How else to explain the tone of their response to the former chief executive officer of Beth Israel Deaconess Medical Center, Paul Levy? As for patients, Samuels and Hadler defend our “humanity.” How…noble.

To me, healing the sick is an act of holiness, not noblesse oblige. Fortunately, we Jews cherish a long tradition of arguing even with God Himself. A famous Talmudic story ends with God acknowledging that even Divine opinion isn’t enough to override the rule of law. Let’s take a closer look at Samuels’s and Hadler’s opinions in relation to the rules of medical evidence.Continue reading…

For Patient Safety: A Reversal. What Can Healthcare Teach the Aviation Industry?

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There are more than 50 in-flight medical emergencies a day on commercial airlines — or one for every 604 flights, according to a study published in 2013.

What are the odds that two emergencies would occur on the exact same flight, above the Atlantic Ocean and hours from the nearest airport?

My colleague Mark, a critical care physician with whom I’d worked as an ICU nurse, and I were traveling to the Middle East for a patient safety conference. We were comfortably tucked into our seats, as he snored next to me.

It must have been about 3 a.m. when I was awakened by an overhead announcement asking for a medical doctor. I nudged Mark, asking him to press his call light.

As the flight attendant approached, I told her that Mark was a doctor.

“And she’s an ICU nurse, and we work together,” he said, gesturing toward me.Continue reading…

The “Business Case” For Patient Safety

Betsy Lehman

Twenty years ago this month, the Boston Globe disclosed that health columnist Betsy Lehman, a 39-year-old mother of two, had been killed by a drug overdose during treatment for breast cancer at Dana-Farber Cancer Center. In laying out a grim trail of preventable mistakes at a renowned institution, the Globe prompted local soul searching and a new focus on patient safety nationally.

Although I didn’t know Betsy personally, we were about the same age, had two kids about the same ages and were in the same profession. (I, too, was a health care journalist.) That’s why I was particularly disappointed by a recent conference celebrating the reopening of the Betsy Lehman Center for Patient Safety and Medical Error Reduction. It was heavy on statistics and poll results; e.g., one in four Massachusetts adults say they’ve seen an error in their own care or the care of someone close to them.

While it’s true that Boston is the epicenter of thinking, writing and speaking about patient safety, words do not always translate into deeds.

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