Tag: Patient Safety

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

Oct 19, 2010• 3

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.

Because it’s on the Interwebs, it must be true

Sep 20, 2010• 4

By Matthew Holt

Locally we’re supposed to diss the SF Weekly because it’s been trying to put the “genuine independent” local free weekly the SF Bay Guardian out of business and has lost a major lawsuit against it. But SF Weekly reporter Ashley Harrel has written an excellent article figuring out that one San Francisco plastic surgeon has paid a marketing company to plaster good reviews about her all over the web, and to make her the number 1 result on Google for “San Francisco Plastic Surgery”. The marketing agency unsubtly used the same name in all its reviews–the actual shortened version of the owner’s name–and has a video up on its site featuring the doctor as a happy client. Not exactly bright. Harrel also reminds us of the case of the chain plastic surgery center LifeStyle Lift that conducted a huge astroturfing operation and eventually settled with the NY Attorney General promising to stop.

Only one person on the San Francisco consumers bible Yelp seems to have noticed about this article but the person who died from a minor procedure hasn’t posted–although a few grumpy others have. (So apparently you either like this doctor or she kills you. My dad the surgeon always said he buried his mistakes!). And frankly that’s true for many patients and many doctors. In any event, the doctor is on probation from the state medical board–although that seems like a slap on the wrist.

The answer is twofold. First, get state medical boards to be more pro-active and aggressive in dealing with bad doctors. But realistically we know where that’s been going for years and its unlikely to change.

The second answer is to get better information in specialized places on the web, and elevate those.

Computer Error or Patient-Centered Care?

Sep 8, 2010• 1

By HERBERT MATHEWSON, MD

The saga continues, but morphs from a discussion of computer error into patient-centered care (1).

In my last two posts I tell my story of trying to speed up a six-hour infusion of intravenous medication by correcting a “computer error”; a “failure to update reference information” in the computer available to the nurses. My first clue was the discrepancy between the medication’s package insert and the computer information. Discussion with the infusion nurses and a call to the Hospital’s chief pharmacist caused a review of the computer info, the package insert, and the hospital’s Pharmacy and Therapeutics Committee minutes.

The package insert stated that “after the initial 30 minutes without a side-effect the infusion rate could be gradually increased to the maximum rate.” The infusion nurses’ interpretation of “gradually” was a infusion rate step-up every 30 minutes resulting in a six-hour infusion. My preference was for a two hour infusion. I looked diligently, and in vain, for the manufacturer’s definition of “gradually”, so I called its 800 number . A very knowledgeable and accommodating RN in the Professional Services Department ( I identified myself as a physician) explained that they did not define “gradually” because they wished “not to be too proscribing, realized that individual patients varied, and respected each facility’s responsibility to set their own protocols.” It sounded like pretty good risk management (avoidance of increased liability) to me. She went on to say that many facilities had used a rate step-up schedule of 15 minutes rather than 30 minutes without increased side-effects and offered to send us the articles describing this.

Going to a step-up rate 0f every 15 minutes rather than 30 minutes would result in a four and a half hour infusion instead of a six hour one; still longer than my initially hoped-for two hours. Could the change in duration be labeled a triumph of “patient-centered care”? If so, was it worth all the time and effort?Continue reading…

The Yellow Stickie Ain’t Dead Yet

Aug 2, 2010• 4

By HERBERT MATHEWSON, MD

I’m sure that many of us “old timers” can remember the early days of computer implementation in our hospitals. At that time you couldn’t help but notice the dozens (or more) Yellow Stickies plastering the nurses’ station computers, usually around the monitor’s edges, filled with keywords, short cuts, new jargon, and other information helpful to them as they strived to give up their dependence on paper. Well, thirty years later, the Yellow Stickie ain’t gone just yet.

I had to go into my hospital last week to get an intravenous infusion to help me with the effects of a neuropathy. The receiving desk at the IV Infusion Center had three computer monitors with two people sitting at them. My physician’s orders were already printed out and were attached to my computer printout encounter form. After receiving my computer generated ID bracelet with bar code, I was lead into a room with four chairs, each one next to a computerized infusion pump with blinking lights and various sounds to convey different messages to the nurses caring for me. Each pump had touch-screen data entry and a multiple color display combined, was capable of at least three distinct alert sounds, and was neatly packaged to fit on a standard IV pole. The combination of four such poles, two automatic blood pressure machines with their display screens and alert sounds, the usual wall of oxygen, suction, electrical outlets, and signal lights, a R2D2-size mobile air conditioning unit standing in the middle of the floor with its coiled, white PVC exhaust duct winding to the wall, and four brand new baby blue Barca Loungers made me think that this is what a passenger cabin on a space ship would look like.Continue reading…

Gawande’s “Checklist Manifesto”

Feb 8, 2010• 5

By BOB WACHTER, MD

Every now and then, I read and enjoy a book, but only later fully appreciate it as its lessons and insights slowly become apparent. Judging by the number of times I’ve said, “That reminds me of Gawande’s observations about ___” over the past month, The Checklist Manifesto is one such book.

In this short, deceptively simple volume, Atul (who I count as both friend and inspiration) discusses the history of “the lowly checklist,” the impact of checklists on various industries, how he came to understand the value of checklists to medical care, and what makes a useful checklist. Most of this content could have been written by a thoughtful healthcare journalist. But Atul put his interest in checklists to practical use, spearheading a WHO initiative to test a checklist-based “safe surgery” program in 8 diverse hospitals around the world, an effort that saved hundreds of lives. His description of this program forms the core of the book.

Which is as it should be, since these autobiographical elements highlight what is unique about Atul, and his book. Yes, he is a gifted journalist (of course, aided by a surgeon’s insider knowledge and access – as demonstrated by last year’s game changing article about healthcare in McAllen, Texas). But he is also a healthcare leader, whose clear aim is not only to explain attitudes and policy, but to change them. It would be as if Malcolm Gladwell had tried to create a Tipping Point himself, and written up the experience. The whole thing gets very “meta” very quickly, and in the hands of a lesser person, might even threaten to become a bit dicey. (Is he a medical George Plimpton – trying out checklists in the OR to provide fodder for his writing?) But there’s no such worry here: Atul’s passion for patients and humility are so obvious that one never questions his methods or motives.

The Patient Safety Movement Turns Ten

Dec 2, 2009• 56

By BOB WACHTER

On December 1, 1999, the Institute of Medicine released a report entitled To Err is Human: Building a Safer Health System. Although its authors hoped to spark a national movement, they had little cause for optimism. After all, early efforts by advocates like Berwick and Leape and organizations like the National Patient Safety Foundation had barely moved the needle of public and professional attention.

The IOM Report succeeded beyond its framers’ wildest dreams, and the movement they spawned turns ten today. Please indulge me while I spend a nostalgic moment recalling the remarkable spin that launched the patient safety field. I’ll then segue to a summary of my assessment of what we’ve accomplished over the past decade (I outline this more fully in an article in this week’s web version of Health Affairs, which I hope you’ll take a look at).Continue reading…

Physician Accountability for Violation of Safety Rules: The Time For Excuses Has Passed

Oct 14, 2009• 12

By BOB WACHTER, MD

Bob wachter

In a recent New England Journal, Peter Pronovost and I make the case for striking a new balance between “no blame” and accountability. Come on folks, it’s time.

At most hospitals, hand hygiene rates hover between 30-70%, and it’s a near-miracle when they top 80%. When I ask people how they’re working to improve their rates, the invariable answer is “we’re trying to fix the system.”

Now, don’t get me wrong. I believe that our focus on dysfunctional systems is responsible for much of our progress in safety and quality over the past decade. We now understand that most errors are committed by good, well-intentioned caregivers, and that shaming, suing, or shooting them can’t fix the fallibility of the human condition.Continue reading…

Another Look: Incident Reporting Systems

Sep 28, 2009• 4

By BOB WACHTER, MD

When the patient safety field began a decade ago with the publication of the IOM report on medical errors, one of its first thrusts was to import lessons from “safer” industries, particularly aviation. Most of these lessons – a focus on bad systems more than bad people, the importance of teamwork, the use of checklists, the value of simulation training – have served us well.But one lesson from aviation has proved to be wrong, and we are continuing to suffer from this medical error. It was an unquestioning embrace of using incident reporting (IR) systems to learn about mistakes and near misses.

The Aviation Safety Reporting System, by all accounts, has been central to commercial aviation’s remarkable safety record. Near misses and unsafe conditions are reported (unlike healthcare, aviation doesn’t need a reporting system for “hits” – they appear on CNN). The reports go to an independent agency (run by NASA, as it happens), which analyses the cases looking for trends. When it finds them, it disseminates the information through widely read newsletters and websites; when it discovers a showstopper, ASRS personnel inform the FAA, which has the power to ground a whole fleet if necessary. Each year, the ASRS receives about 40,000 reports from the entire U.S. commercial aviation system.

Interview: Bob Wachter on reform, safety, primary care and everything

Aug 19, 2009• 4

By MATTHEW HOLT

Robert_wachter

One of the best commentators around on the issues of patient safety, health care quality and basically everything to do with health care organizations is UCSF Professor Bob Wachter. Bob has been in the trenches as one of the leaders in the hospitalist movement, a major driver behind improving patient safety, and has also straddled the worlds of medical practice as a PCP, academia at UCSF, and been publicizing this all to a wider audience–particularly with his 2005 book Internal Bleeding and his more recent book Understanding Patient Safety. Then of course there are his occasional blog posts both on Wachter’s World and here on THCB.

This was a really fun conversation and somehow Bob remains an optimist. Here’s the interview.

Op-Ed: The Unintended Consequences of “No Pay for Errors”

Jul 21, 2009• 3

By BOB WACHTER, MD

Medicare’s policy to withhold payment for “never events” – the first effort to use the payment system to promote patient safety – remains intriguing and controversial. To date, most of the discussion has focused on the policy itself at a macro level (including two articles by yours truly, here and here).

In the past month, experts on two of the adverse events on the “no pay” list – hospital falls and catheter-associated urinary tract infections – have chimed in. Interestingly, while agreeing that the overall policy has upsides and risks, they came to strikingly different conclusions about the wisdom of including their pet peril on the list.

Let’s begin with UTIs. Last month’s Annals of Internal Medicine article by Michigan’s Sanjay Saint and colleagues begins, quite cleverly, with a quote from Ben Franklin: “By failing to prepare, you are preparing to fail.” Turns out that among Franklin’s many inventions was the flexible urinary catheter (so who the hell was Foley?). The piece nicely reviews the “no pay” policy and describes the epidemiology of catheter-associated UTI (CAUTI).Continue reading…