Tag: Patient Safety

Top-Down vs. Bottom-Up

Sep 28, 2011• 2

By BOB WACHTER, MD

In my last post, I discussed the role of physicians in patient safety in the US and UK. Today, I’m going widen the lens to consider how the culture and structure of the two healthcare systems have influenced their safety efforts. What I’ve discovered since arriving in London in June has surprised me, and helped me understand what has and hasn’t worked in America.

Before I arrived here, I assumed that the UK had a major advantage when it came to improving patient safety and quality. After all, a single-payer system means less chaos and fragmentation—one payer, one regulator; no muss, no fuss. But this can be more curse than blessing, because it creates a tendency to favor top-down solutions that—as we keep learning in patient safety—simply don’t work very well.

To understand why, let’s start with a short riff on complexity, one of the hottest topics in healthcare policy.

Complexity R Us

Complexity theory is the branch of management thinking that holds that large organizations don’t operate like predictable and static machines, in which Inputs A and B predictably lead to Result C. Rather, organizations operate as “complex adaptive systems,” with unpredictability and non-linearity the rule, not the exception. It’s more Italy (without the wild parties) than Switzerland.

Complexity theory divides decisions and problems into three general categories: simple, complicated, and complex. Simple problems are ones in which the inputs and outputs are known; they can be managed by following a recipe or a set of rules. Baking a cake is a simple problem; so is choosing the right antibiotics to treat pneumonia. Complicated problems involve substantial uncertainties: the solutions may not be known, but they are potentially knowable. An example is designing a rocket ship to fly to the moon—if you were working for NASA in 1962 and heard President Kennedy declare a moon landing as a national goal, you probably believed it was not going to be easy but, with enough brainpower and resources, it could be achieved. Finally, complex problems are often likened to raising a child. While we may have a general sense of what works, the actual formula for success is, alas, unknowable (if you’re not a parent, trust me on this).

We’re From The Government. We’re Here To Help …

Sep 11, 2011• 5

By WHITECOAT, MD

The clock is ticking for Parkland Memorial Hospital in Dallas.

Earlier this month, Parkland was cited by the Centers for Medicare & Medicaid Services for several “serious threats” to patient safety. As a result, the hospital is now in jeopardy of losing its ability to participate in the Medicare program unless it submits “correction plans” to CMS by August 20, 2011.

According to a CMS spokesperson, two violations relating to infection control and emergency care issues were “so serious that they triggered ‘immediate jeopardy’” for the hospital. In fact, the reasons for the citation were so heinous that CMS won’t even disclose them to the public until Parkland submits plans on how to fix those super secret problems. That’s the subject of another WTF discussion, but we’ll save that one for later.

The event triggering the CMS investigation involved a schizophrenic psychiatric patient with a heart condition who died while in the emergency department. The report states that the technicians who subdued the man did not have “effective training” and that the patient was not closely monitored before his death.

According to the article and an interview Parkland’s Chief Medical Officer, Parkland was cited for several reasons. Based on what I can gather from the article, two of the hospital’s citations were for:

– Moving patients with less serious symptoms to a separate urgent care center for medical screening
– Staff touching a patient and then touching other surfaces that people would come into contact with

Think about how grave these dangers are.

Work Hour Restrictions – A Painful Gift to Medicine

Aug 25, 2011• 2

By VIPAN NIKORE, MD

When I completed my overnight shift and left the Medical ICU the morning of July 1, I raised my arms victoriously. I uttered, “Finally, internship is done!” I may have been one of the last to speak such words.

As of July 1, 2011, intern year forever changed. In the world of medicine the first year of residency, or intern year, is when doctors earn their stripes. Traditionally it is the most demanding year in a decade-long quest to become a practicing physician. But this year, the Accreditation Council of Graduate Medical Education (ACGME) mandated that interns can no longer work more than 16 hours straight, and must have 10 hours off between shifts. Second- and third-year residents can still work 28-hour shifts, but no more 30-hour shifts for interns.

To the outsider, this may seem like a common sense change that would only improve patient safety. Within the medical field, however, this change is arguably the most controversial in the history of medical education.

Advocates believe these duty-hour modifications will decrease medical errors and improve unacceptable working conditions for residents. ACGME officials still believe that residents should be able to handle the vigorous hours and workload, but believe launching the least experienced physicians — new interns — into those demanding conditions just days after medical school is inappropriate and unsafe. As well, the general public generally favors the new changes.

When It Comes to Patient Safety, Caution Isn’t a Four-letter Word

May 18, 2011

By JORGO CHATZIMARKAKIS

Around the world and now in the United States, there is a broadening discussion of how best to proceed down the path of approving and getting to market medicines called biosimilars. Biosimilars are non-identical copies of next generation medicines known as biologics. As the U.S. begins establishing new guidance for biosimilars, regulators and legislators should look to the European Union model on guidance policy and approve these important, often life-saving, drugs when they are proven to be safe for the patients they are intended to heal.

There is justified debate and concern both here in the EU and other nations on how best to introduce biosimilars into the marketplace. We know from the science, that it’s immensely more difficult to produce a biosimilar than a generic version of a traditional drug. And with this increased difficulty, comes increased risks to patients in the form of efficacy and drug-to-drug interactions. However, by adding biosimilars to the treatment regimen, we can hope to see long-term therapy at the lower costs that biosimilars may be able to provide. This is important to every country struggling to meet the demands of an aging population and rising health care costs.

As policymakers this dilemma is made easier because our focus must always be on patient safety. Citizens trust that their nation’s regulatory bodies are looking out for their best interests and doing their due diligence to ensure a safe drug supply. So patient safety is our starting point, our ending point, and our path along the way.Continue reading…

The Hospitalist Field Turns 15: What The Past Says About The Future

May 16, 2011

By BOB WACHTER, MD

I just returned from the Society of Hospital Medicine’s annual meeting in Dallas. Seeing more than 2,000 hospitalists in one place is remarkable, since I remember the days when we all fit into a mid-sized conference room at a Holiday Inn.

I have clearly assumed the mantle of elder statesman at these meetings. I find this odd, since my idea of an elder statesman is UCSF’s former chair of medicine, Lloyd Hollingsworth (“Holly”) Smith, a man of unbelievable accomplishment and grace. Holly is now in his late 80s, and every year we ask him to say a few words at our department’s annual faculty dinner. Holly is the best after-dinner speaker I know – his comments, always insightful and hilarious, are increasingly peppered with “old guy” references (my recent favorite: “I’ve now reached the age of – when I reach down to tie my shoes, I ask myself, ‘Is there anything else I need to do as long as I’m down here?’ before I get up.”)

I’m not complaining: for the past decade, I’ve had the honor of giving a closing keynote address at the annual hospital medicine meeting. In this week’s talk, I reflected on the history of the hospitalist field, in the 15 years since Lee Goldman and I coined the term in the New England Journal of Medicine.

This kind of reflection is useful because, in a world in which we’re all drinking out of a huge information hose, it’s easy to focus on the short term and lose track of the arc of history. Self-help guru Tony Robbins had it right when he said, “Most people overestimate what they can do in a year, and underestimate what they can do in a decade.” Our 15-year history proves that.Continue reading…

Let’s Just Keep Killing and Maiming Them

May 10, 2011• 16

By PAUL LEVY

Old patterns die hard. Back in March 2010, I posted a chart from the ACHE that Jim Conway had sent me showing a decrease in the ranking of quality and safety among priorities reported by hospital executives.

Now comes an article in Health, Medical, and Science Updates about a study by the Beryl Institute, entitled “The State of Patient Experience in American Hospitals.” Of those places surveyed, 51% were individual hospitals and 49% were hospital groups or systems. There was an even mix of urban, suburban, and rural facilities.

As in the prior ACHE survey, 69% of hospital executives rank things other than quality and patient safety as top priorities.

Any way you look at it, this is quite simply a failure of leadership and governance in American hospitals. There is a strange adherence to the view that “these things happen,” an apparent belief that a certain level of harm that occurs to patients is just the way things should be. It is as though the medical profession, hospital administrators, and hospital trustees have decided that the current amount of harm is the statistically irreducible level.Continue reading…

I Wish We Were Less Patient

May 5, 2011• 7

By PAUL LEVY

The sad case of Kimberly Hiatt, a Seattle nurse who committed suicide months after being disciplined for administering a fatal dose to an infant, is starting to make the rounds. Josephine Ensign, for example, concludes her blog post on this by saying:

I am left with many questions. Why was the nurse treated so differently from the dentist or physician at the same hospital for similarly serious medication errors? If one in three hospital patients in the US experiences serious preventable adverse events and we know that it’s “the system, stupid,” why are most of our efforts put into educating patients to advocate for safer care? If nurses are simultaneously being told by hospital administrators to report errors and then facing serious retribution for making honest unintentional mistakes . . . what do I teach my students to do?

We can never know, of course, whether the suicide was related to the incident itself, the disciplinary action, or indeed, some other aspect of Hiatt’s life. But the sequence of events will cause many to draw the connection between the way Hiatt was treated after the accident and her death. In any event, though, the ambiguity as to whether or not it was connected does not take away from the kinds of questions raised by Ensign.Continue reading…

The Science and Religion of Patient Safety

Apr 12, 2011• 3

By BOB WACHTER, MD

Earlier today, Secretary of Health and Human Services Kathleen Sebelius and Medicare chief Don Berwick announced the “Partnership for Patients,” a far-reaching federal initiative designed to take a big bite out of adverse events in American hospitals. The program – which aims to decrease preventable harm in U.S. hospitals by 40 percent and preventable readmissions by 20 percent by 2013 – marks a watershed moment in the patient safety movement. Here’s the scoop, along with a bit of back story (which includes a gratifying bit part for yours truly).

Last July, I attended the American Board of Internal Medicine’s Summer Forum in Vancouver. This confab has turned into medicine’s version of Davos, drawing a who’s who in healthcare policy. One of the attendees was an old friend, Peter Lee, a San Francisco lawyer and healthcare consumer advocate who had just been asked to lead a new Office of Delivery System Reform within the U.S. Department of Health and Human Services. Peter’s charge was to figure out how to transform the delivery of healthcare in America, challenging under any circumstances but Sisyphean given that he’d be pushing the rock up a mountain chock full of landmines comprised of endless legal and political threats to the recently-passed Affordable Care Act.

Fueled by the enthusiasm of being a new guy with a crucial task, Peter took advantage of some conference downtime to convene a small group – about 20 of us – to advise him on what he should focus on in his new role. After soliciting ideas from many of the participants around the table, he turned to me. I decided not to be shy.

I suggested that the topic of patient safety remained compelling and scary, and that it might be at a tipping point – with new success stories in reducing infections and improving surgical safety, more hospitals possessing the infrastructure to improve safety, and increasing penetration of IT systems due to federal support through the meaningful use standards. I also knew that Don Berwick, Peter’s new boss, would not be content to move around some bureaucratic chess pieces, or even a few hundred million dollars. Instead, he’d be looking to do Something Big – an initiative aimed at capturing hearts and minds, a federal version of his IHI 100,000 Lives and 5 Million Lives campaigns. What better target than patient safety?Continue reading…

The Partnership for Patients: The Inside Scoop on a Game Changing Safety Initiative

Apr 12, 2011

By BOB WACHTER, MD

Why We Still Kill Patients

Apr 8, 2011• 36

By MICHAEL MILLENSON

A recent front-page article ^[1] in the New York Times conveyed grim news about patient safety. The first large-scale study ^[2] of hospital safety in a decade concluded that care has not gotten significantly safer since the Institute of Medicine’s 1999 estimate ^[3] 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.