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Tag: Patient Safety

A Game-Changing Statistic: 1 in 250

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By BOB WACHTER

Bob Wachter

Although the medical profession has been harming unlucky patients for centuries, the patient safety movement didn’t take flight until 1999, when the Institute of Medicine published its seminal report, To Err is Human. And that report would have ended up as just another doorstop if not for its estimate that 44,000-98,000 Americans each year die from medical mistakes, the equivalent of a jumbo jet crashing each day.

Come to think of it, the quality movement also gelled after the publication of Beth McGlynn’s 2003 NEJM study, which produced its own statistical blockbuster: American medical care comports with evidence-based practice 54% of the time, a number close enough to a coin flip to be unforgettably disturbing.

These two examples demonstrate the unique power of a memorable statistic to catalyze a movement.

Last month, my colleague Rebecca Smith-Bindman, professor of radiology, epidemiology, and ob/gyn at UCSF and one of the nation’s experts in the risks of radiographs, gave Medical Grand Rounds at UCSF. Her talk was brimming with amazing statistics, but this is the one that took my breath away:

A 20-year old woman who gets an abdominal-pelvic CT scan (i.e., just about any young woman coming to the ED with belly pain) has a 1 in 250 chance of getting cancer from that single scan.

Did that fully register? One CAT scan, which until recently most of us ordered with no more restraint than we exhibit when asking the Starbucks barista for a tall latte, will cause cancer in one out of every 250 patients. Two-hundred fifty: that’s the number of students in my college Bio 101 class. Wow.Continue reading…

Truth or Consequences

Paul Levy 1 By PAUL LEVY

While we are on the topic of medical errors, let’s see how doctors feel about disclosing them when the patient has not been harmed. Medscape recently surveyed doctors on this question and published the results in a provocative article by Gail Garfinkel Weiss entitled: ‘Some Worms Are Best Left in the Can’ — Should You Hide Medical Errors?” (A subscription is required, but it is free.)

To the doctors reading this, into which camp do you fall? To the patients reading this, what would you expect of your doctor in this kind of situation?

Some excerpts:

In response to the question “Are there times when it’s acceptable to cover up or avoid revealing a mistake if that mistake would not cause harm to the patient?” 60.1% of respondents answered “no,” and the remaining respondents were almost evenly divided between “yes” (19%) and “it depends” (20.9%).

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What Do Medical Errors Cost Your State?

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By PAUL LEVY

GE Healthcare offers this calculator, based on data from the Society of Actuaries, to show the cost of medical errors for a given population. I inserted the population of Massachusetts from the most recent US Census to see what would pop up. Here is the result.

I suspect this figure of $260+ million is actually an underestimate because there is a lot of preventable harm that does not get counted as such. For example, we reduced our rate of ventilator associated pneumonia at BIDMC considerably over the last three years by rigorous application of the VAP bundle. Likewise at Cooley Dickinson Hospital in Northhampton, MA.

As best as I can tell, VAP is not included in the statistics above. Chances are those cases previously would not have been counted as medical errors. They were just part of the mentality of “these things happen,” a belief by many that the current level of harm caused by hospitals is a statistically irreducible number.

Notice that I say “caused by hospitals,” and not “occurring in hospitals.” Until we take ownership of the fact that a great degree of harm that occurs in hospitals is caused by failures in the manner of delivering care, we will not make progress.Continue reading…

The Moral Component to Transparency

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By PAUL LEVY Paul Levy 1

Many of you have asked if I intend to continue this blog, now that I am stepping down as CEO of BIDMC. Yes. (I’ll have to change the name. How about “The blog formerly known as . . . ” or just a simple “Not Running a Hospital”?)

Please expect a combination of commentary on current events and issues. But also please expect an occasional lesson or two from my experience of the last nine years, all offered in the hope of being helpful to others in the field. I apologize in advance if some portions seem self-aggrandizing or self-praiseworthy. I don’t mean them that way, but sometimes, to be historically accurate, I’ll have to include a few good things about myself!

Here we go. Act 2.

In a comment on a post below, author Charles Kenney asks:

Isn’t there a compelling — perhaps even overriding — moral component to transparency?

The answer, of course, is yes. Doctors and others pledge to do no harm. How can you be sure you are living by that oath if you are unwilling to acknowledge how well you are actually doing the job? As scientists, how can you test to see if you are making improvements in evidence-based care if you cannot validate the “prior” against which you are testing a new hypothesis? At the most personal, ethical level, how can you be sure you are doing the best for people who have entrusted their lives to you if you are not willing to be open on these matters?

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The Non-Scalability of Charisma

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By BOB WACHTER, MD

Early on, many social movements depend on a charismatic leader to focus attention, build a burning platform, and inspire people to action. You know when the movement has made it when it no longer needs such a leader for fuel.

The safety and quality movements have picked up tremendous steam over the past decade, but they haven’t yet hit that self-sustaining tipping point. Last week, there were two things that reminded me of this: the announcement of a new leader of the Institute for Healthcare Improvement (IHI), and a doleful JAMA essay by Peter Pronovost.

During the circus that was Don Berwick’s recess appointment to lead the Centers for Medicare & Medicaid Services (CMS), all eyes were trained Inside the Beltway. But 440 miles north, in Cambridge, MA, arguably the most important organization in the quality and safety galaxy needed to get on with its business. On July 8th, IHI announced its choice of Maureen Bisognano to become its new CEO. Maureen is a nurse and former hospital exec who has spent the last 15 years at IHI as Don’s consigliere. She is a terrific person, with boundless energy and great organizational skills – insiders will tell you that she was the reason that IHI’s trains ran on time for the past decade, as Don is the quintessential big picture guy.Continue reading…

Could It Be That Patients Aren’t Any Safer?

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By ROBERT WACHTER, MDPicture 16

On the occasion of last year’s tenth anniversary of the IOM Report on medical mistakes, I was asked one question far more than any other: after all this effort, are patients any safer today than they were a decade ago?

Basing my answer more on gestalt than hard data, I gave our patient safety efforts a grade of B-, up a smidge from C+ five years earlier. Some commentators found that far too generous, blasting the safety field for the absence of measurable progress, their arguments bolstered by “data” demonstrating static or even increasing numbers of adverse events. I largely swatted that one away, noting that metrics such as self-reported incidents or patient safety indicators drawn from billing data were deeply flawed. Just look at all the new safety-oriented activity in the average U.S. hospital, I asked. How could we not be making patients safer?

I may have been overly charitable. This week, in an echo of the Harvard Medical Practice Study (the source of the 44,000-98,000 deaths/year from medical mistakes estimate, which launched the safety movement), a different group of Harvard investigators, led by pediatric hospitalist and work-hours guru Chris Landrigan, published a depressing study in the New England Journal of Medicine. The study used the Institute for Healthcare Improvement’s Global Trigger Tool, which looks for signals that an error or adverse event may have occurred, such as the use of an antidote for an overdose of narcotics or blood thinners. Following each trigger, a detailed chart review is performed to confirm the presence of an error, and to assess the degree of patient harm and the level of preventability. While the tool isn’t perfect, prior studies (such as this and this) have shown that it is a reasonably accurate way to search for errors and harm – better than voluntary reports by providers, malpractice cases, or methods that rely on administrative data.

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The Decade-Long Journey To NEJM Case 34-2010

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By BOB WACHTERPicture 16, MD

The most popular article in last week’s New England Journal of Medicine did not tout the discovery of a novel gene, nor describe a cardiology clinical trial with a clever acronym as its title. Rather, it was the report of a case in which a surgeon at the Massachusetts General Hospital performed the wrong operation on a 65-year-old woman.

This was a breakthrough for the Journal – the first time in its storied 86-year history that the Case Records of the MGH published such a report. But it was not the first opportunity the NEJM had to publish such a piece… that occurred a decade earlier. The story of the path from then to now reflects the evolution of the patient safety movement. It’s a story I know well since it involved one of the lowest points in my professional life.

Before I share the back story, a word on last week’s article. David Ring, a prominent Harvard hand specialist, performed a carpal tunnel release on a patient who actually needed a trigger finger release – an entirely different operation. Showing great courage, Ring described his own error, with safety expert Gregg Meyer providing the color commentary.

As always, the pathophysiology of this misfire was a combination of active (i.e., somebody did something wrong) and latent (the system was a setup for failure) errors that jibed entirely with Jim Reason’s famous “Swiss cheese model” of “organizational accidents.”

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Contemplating Safety While Lying Down

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By JESSIE GRUMAN, PhDJessie Gruman

I write about what it takes for us — whether we are sick or well — to find and make good use of health care today.

At the end of September I was hospitalized for surgery to remove a tumor in my stomach. Below is one in a series of five observations about my experiences since then.

“You have to get out of this hospital – it’s a dangerous place,” each of my physician friends exclaimed when they came to visit me during my recent stay after surgery for stomach cancer.

Jeez!  I know! Prior to my operation, I was more preoccupied by the possibility of medical errors than of the operation itself or the pain it might cause.  What if they take out my kidney instead of my stomach?  Or leave a sponge in there?  Or over-hydrate me so I drown? What if one of my many overnight vitals-taking-shot-givers infects me with MRSA?

The human imagination has wondrous capacities, especially when fueled by true stories of harm people have experienced due to medical errors.  I read closely the IOM report To Err is Human: Building a Safer Health System ;  I am horrified by the medical errors experienced by Sue Sheridan and impressed by her leadership of Consumers Advancing Patient Safety and  Diane Pinakiewicz’s at the National Patient Safety Foundation to raise awareness about the dangers patients face due to carelessness and lack of system-level controls.

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Medicare Costs Rise, Health Outcomes Suffer When Seniors Are Over-Medicated

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By NAOMI FREUNDLICH

The problem of elderly people taking too many medications is not new, but continues to pose a serious risk to health as well as contribute significantly to rising Medicare costs. The fact is that nearly 20% of adults aged 65 years and older who are not hospitalized take 10 or more medications daily. This number is not the result of shoddy care, but rather achieved when doctors simply follow practice guidelines for several common, co-existing conditions like diabetes, high blood pressure and depression, for example. If you look at all seniors (those both in and out of the hospital) the American Society of Consultant Pharmacists reports that the average 65-69 year old takes nearly 14 prescriptions per year; by ages 80-84 that number averages an astounding 18 prescription drugs per year.

What’s troubling is that instead of improving the health of seniors, evidence is growing that the more medications an elderly person takes, the more likely he is to experience falls, cognitive decline, loss of mobility, depression and even cardiac problems. These adverse drug effects may be mistaken for Alzheimer’s disease or other dementias too. The bottom line: Experts estimate that up to one-third of the elderly in our communities may be over-medicated and some 20% of their hospital admissions are due to adverse drug events. The costs related to over-medication in the elderly are thought to exceed $80 billion each year.

Although the problem of so-called “polypharmacy” among seniors results in significant economic and public health costs, little has been done to remedy the problem. In fact, in a recent commentary in the Journal of the American Medical Association, Jerry Avorn, associate professor of medicine at Harvard Medical School and author of the book “Powerful Medicines,” says that “many aspects of the US health care system act to discourage optimal prescribing” for the elderly.

For example, elderly Americans are highly underrepresented in the clinical trials for many of the drugs that doctors commonly prescribe for them. Seniors may metabolize these medications differently and they are often more sensitive to side effects and counter-indications with other drugs than younger people. They also take many more drugs (often all at the same time) than any subjects who take part in controlled clinical trials. Disturbingly, doctors sometimes end up prescribing a new medication to treat the adverse effects of a pill the elderly patient has been taking for years.

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PBM Industry Reforms can Reduce Wasteful Health Care Spending, Protect Patient Choice of Pharmacy

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By CSS

American businessman Victor Kiam best described the small business owners’ mindset by declaring, “An entrepreneur assumes the risk and is dedicated and committed to the success of whatever he or she undertakes.” However, external forces can occasionally constrain even the most astute entrepreneur, as is the case with independent community pharmacy owners. These same forces needlessly inflate prescription drug costs for employers and health plan sponsors, while undermining patient choice and health outcomes.

Pharmacy benefit managers (PBMs) are hired by employers, government agencies, health insurance plans and unions to administer prescription drug plans. They morphed over time from simple claim adjudicators to gigantic drug middlemen operating a byzantine drug delivery system that benefits them at the expense of others. They reap windfall profits simply for processing claims and operating mail order pharmacies. In 2009, the three largest PBMs – CVS Caremark (which includes the CVS pharmacy retail chain), Medco Health Solutions, and Express Scripts – made $6.4 billion, $1.1 billion and $776 million respectively in profits. By contrast, independent pharmacies operate off of slim profit margins that are driven by prescription drug reimbursement. Despite the rising cost of many medicines, these rates have been declining for years.

Local pharmacists have a Hobson’s choice: accept onerous, non-negotiable contract terms dictated by PBMs or lose access to both new and long-term patients. When the contracts are signed community pharmacies are dragged into a profit-draining, bureaucratic abyss. If they have the temerity to complain, PBMs can often freely void the contract. U.S. Representatives Anthony Weiner (D-NY) and Jerry Moran (R-KS) introduced H.R. 5234, the PBM Audit Reform and Transparency Act of 2010; a bipartisan-supported bill designed to tackle some of the most egregious practices of the PBM industry. Its passage is a must. 

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