Tag: Patient Safety

Battling MRSA with transparency

Nov 17, 2008• 3

By Sarah Arnquist

Sarahmug Two weeks ago, I made an emergency trip home to Minnesota because my grandmother fell ill. She went to the emergency room on a Sunday night, complaining of fatigue and shortness of breath.

The emergency physician diagnosed her with pneumonia and admitted her for the night. Two days later, she was transferred to the intensive care unit and put on a ventilator. My grandma is only 74, healthy and energetic. Her rapid decline shocked my family.

My grandma, however, had not been taking good care of herself since her husband died three weeks earlier. He had many health issues, but at the end, died of MRSA pneumonia. My grandmother slept by his side, caring for him daily during his last days.

No one from the nursing home hospice program or the hospital warned my grandma about the seriousness of this drug-resistent staph infection. No one suggested she take precautions to protect herself or that she be tested as a carrier.

Can a Hospital Afford to Share Its Warts with the Public?

Nov 3, 2008• 3

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By BOB WACHTER, MD

Paul Levy, the blogging CEO at Boston’s Beth Israel Deaconess Medical Center, has staked his – and his hospital’s – reputation on a culture of transparency. Although no doubt partly driven by Paul’s ethical compass, he must also hope that his unique brand of openness will be good for business.

But will it be?

An article in last week’s Boston Globe left me unsure. In it, reporter Patricia Wen describes Levy’s culture of openness (which has included a unilateral decision to lay bare data on hospital-acquired infections – making him the skunk in the room at Boston hospital CEO cocktail parties – and rapid and forthright mea culpas after serious errors), juxtaposing it against several recent reports of high profile mistakes and tragedies at BI-D, including a wrong-site surgery case and the death of a young woman during childbirth. Although the article raises the possibility that Levy’s openness is enhancing safety, I think most readers will come away with the impression that these high profile errors illustrate that Beth Israel might well be riskier than other hospitals.

I can’t prove it, but my guess is that this impression would be dead wrong. Knowing about the groundbreaking work BI-Deaconess has done in simulation, teamwork training, quality improvement, patient-centeredness, developing one of the nation’s first procedure services and a high quality hospitalist program, and educating trainees in quality and safety science – as well as knowing what I know about the strength of the faculty and housestaff – I find it nearly inconceivable that the hospital is less safe than the average facility, and likely that it’s safer. Plus they have a boffo information technology system, led by their indefatigable (and blogging) CIO, Dr. John Halamka.

The problem, as usual, boils down to the core challenge of measuring patient safety. Until we can figure out how to determine whether a hospital is safe using standardized data and definitions, we remain dependent on self-reports of errors. So a hospital that has convinced its nurses and docs to fess up to mistakes and chosen to be open about these errors to promote organizational change may appear to be riskier than others with fewer reports, while actually being far safer. This is how a hospital like BI-D, which is doing all of these things to an unprecedented degree, can look like an Error Hot-Spot to the media and public while possibly being the safest show in town.

Is this fair? Of course not. Is it predictable? Absolutely. What should we do about it? We must educate the media about this fact: if you are not hearing about serious errors from other hospitals, trust me – it is because you’re not hearing about them, not because they’re not happening. This is a case in which the obvious (I just heard about another bad error from Hospital A – it must be less safe than Hospital B) might well be dead wrong.

As Levy concludes in his blog posting today,

…in today’s electronic environment, it is virtually impossible to keep data ‘private’ if it is sufficiently distributed to the hospital’s staff. So, if you don’t want the public to know, don’t even tell your own people!

If media coverage convinces the Paul Levys of the world that the better, safer course is to play the old game of “hide the ball” – or convinces hospital boards that they shouldn’t hire CEOs who favor transparency – then this type of reportorial error will cost lives, just as surely as medical errors do.

Robert Wachter, MD, is widely regarded as a leading figure in the modern patient safety movement. Together with Dr. Lee Goldman, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine. His most recent book, Understanding Patient Safety, (McGraw-Hill, 2008) examines the factors that have contributed to what is often described as “an epidemic” facing American hospitals. His posts appear semi-regularly on THCB and on his own blog, Wachter’s World.

Pitfalls of VIP Syndrome

Oct 30, 2008• 2

By Sarah Arnquist

Slate has an article today by two doctors discussing VIP syndrome in health care and how it can lead to worse care for the rich and powerful, such as Sen. Ted Kennedy, who following a diagnosis of cancer convened his own tumor board.

The authors lay out the pitfalls of VIP syndrome here:

VIP syndrome affects not only treatment but also testing decisions. If
Joe the Plumber requests a CT scan he doesn’t need, doctors simply say,
"No, Mr. Plumber." But Joe Biden can get any CT he wants. Some health
care programs
for corporate executives even involve routine full-body CT scans as
screening tests as part of the "chairman’s physical." The problem is
that these expensive and detailed tests may actually increase the risk
of cancer from radiation exposure
and have never really been shown to improve anyone’s health. And if
there is an incidental finding, as there often is, more tests might be
ordered, which may lead to unnecessary biopsies. And doctors perform
heroic procedures on VIPs not just when there is clear benefit but when there is any question of benefit.

Bob Wachter wrote a few months ago about VIP Syndrome, noting there is a sizable medical literature documenting this shift in practice for the rich and powerful.

Wachter writes, "Every hospital I know keeps some sort of a VIP list, a tripwire to
alert the organization of the arrival of a dignitary or billionaire.
Even when there isn’t a formal list, you can be sure that a single call
to the CEO’s office is more than enough to lift the velvet rope. That’s
a simple fact of life, and to me, not worthy of a big fuss. Unless,
of course, they’re getting better care than Joe and Jane Average. But
are they? Believe it or not, I really doubt it."

Something interesting that both articles point out is that the top researcher or surgeon often directs the care or operates on the VIPs. Often, these top doctors haven’t been in the OR for a long time.

Overregulating patient safey

Oct 21, 2008• 3

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By Bob Wachter

In responding to dysfunctional systems, America instinctively turns to “more regulation” (Exhibit A: today’s Wall Street). But regulation can, and often does, go too far, and – in patient safety – I believe that it now has.

Note that this comes from someone who believes that health care was under-regulated
until recently, not a popular viewpoint (just more mavericky behavior,
I guess). But you must admit that it was rather odd that until 5 years
ago, I was more likely to have my order read back when I called my
Chinese takeout restaurant than when I called my hospital ward with a
complex medication order. (Parenthetically, the reason for this
disconnect is that my takeout restaurant has a more powerful business
case to avoid screw-ups – they lose a customer – than does my
hospital). So now there is a Joint Commission requirement to perform
“read-backs” of important verbal communications. And it’s hard to
question the need for regulation when a prescription that said, “Inject
10U Insulin,” could be followed without question, despite the fact that
such orders have been mistaken for “100 Insulin” thousands of times,
leading to scores of patient deaths.

I reviewed the first 5 years of the patient safety field a few years ago. In an article in Health Affairs,
I opined that increased regulatory/accreditation pressure had been the
most potent force for change in the first years of the safety
revolution:

Because physicians remain highly
individualistic (which causes them to resist regulatory solutions and
standardization), and hospitals continue to lack a robust set of
incentives to drive patient safety, regulatory solutions have arguably
been the most important early step, particularly when it comes to
procedural safety (creating safe systems, standardization, and
redundancies) in hospitals.

MRIS: The good, the bad and the useless

Oct 20, 2008• 4

By Christine Gray

Note: This post first appeared at e-patients.net

Gina Kolata’s must-read article in last week’s Science Times points out vast differences in the quality of MRI’s as well as vast differences in the expertise of the radiologists who interpret them.

Patients need to understand this, because physicians sure as Hades aren’t going to tell you.

Kolata uses sports injuries as example. With suspected cancers, the stakes are life and death. A poor MRI was part of the reason my daughter nearly failed to get a proper diagnosis of a malignant sarcoma in her arm, and then nearly failed to get the proper treatment.

Using clinical decision support to get the right diagnosis the first time

Oct 10, 2008• 8

By Joseph Britto, MD

Joseph Britto is co-CEO of Isabel Healthcare, a clinical software vendor that helps clinicians with diagnosis. He practiced medicine in the UK before joining with co-CEO Joseph Maude to start Isabel, named after Joseph’s daughter who was wrongly diagnosed with Chicken Pox and nearly died as a result. Joseph has a personal connection as he was the physician in charge of Isabel’s recovery.

Remember President Bush’s goal, first stated in the 2004 State of the Union message, of giving “every American” his own EMR by 2014?

That goal seems as elusive as ever, especially in light of a recently released study by the The Center for Studying Health System Change which found a discouragingly low rate of EMR adoption among physicians. The new study, released last month, reported that only 29 percent of the hospitals surveyed were actively supporting physician acquisition of EMRs through financial or technical support. This number was disappointing in light of the current government initiative that has relaxed federal rules on physician self-referral and made available hundreds of millions of dollars in various subsidies for EMR adoption by physicians.

Many health policy experts believed that “if you subsidize it, they will come.” While that approach has worked in persuading people to take mass transit, it hasn’t lured many physicians into using EMRs.

Why the reluctance? One reason is cost. On September 25, 2008, the Certification Commission for Healthcare Information Technology (CCHIT) issued a report that reviewed 90 EMR incentive programs (state, federal, private) with a total funding of $700 million available.

Big administrator is watching you

Sep 29, 2008• 4

Robert_wachter By Bob Wachter

Last week, came the announcement that Suzanne Delbanco, founding director of the Leapfrog Group, has assumed the presidency of a company that tracks compliance with safety and quality practices via remote video. Big Brother, meet the Joint Commission.

The report, in Modern Healthcare, describes the process this way:

Video auditing refers to a system in which cameras are mounted in targeted locations to continuously capture specific clinical processes, such as observing handwashing and hand-sanitizing stations. [Using video] fed through a Web-based link, independent, third-party observers audit the recordings and provider reports on safety incidents.

Did you ever doubt this was coming? Virtually every other industry with compliance standards has long used video to monitor compliance and to goose workers into following the rules. If video surveillance is good enough for Vegas croupiers and Kansas meat packers, why wouldn’t it be good enough for neonatal nurses and ER docs?

Mixed reception for hospital ID bracelets

Sep 26, 2008• 2

By Sarah Arnquist

Color-coded hospital bracelets intending to identify categories of patients and prevent errors by ensuring they receive proper care have received a mixed reception, the New York Times reports.

Red bracelets indicate allergies, amber says the patient has a falling risk and purple tells hospital staff that the patient has a not resuscitate order. The DNR bracelets seem to be attracting the most criticism.

Apparently, the Joint Commission warns that the purple bracelets may "brand" patients by their end-of-life choice, and may upset family members unfamiliar with the patient’s wishes.

Are those really legitimate reasons for blocking greater uptake of this seemingly simple and pragmatic strategy to improve patient care and ultimately deliver the care the patient wants?

A Genius Shines…And, Where the Light Doesn’t, Hospitals Don’t

Sep 25, 2008

By Michael L. Millenson

It doesn’t take a genius to figure out that hospitals could dramatically reduce the hundreds of thousands of deaths and injuries they unintentionally cause patients ever year, but it may take a genius to coax change out of ossified organizations. As for getting hospitals to publicly disclose injuries and deaths the law says they must? That’s another story entirely.

On the good news front, The MacArthur Foundation has just honored Johns Hopkins’ Dr. Peter Pronovost with a “genius award,” the informal moniker for the go-and-do-smart-stuff prize given to MacArthur Fellows.

Pronovost, you may recall, is the critical care physician who came up with the idea of culling lengthy guidelines on error prevention in the ICU into a simple checklist of five precautionary steps. When tested in ICUs throughout Michigan, the result was to “change the culture of [the] institutions in the interest of reducing the risk of medical errors and hospital-acquired infections,” the foundation noted. “Pronovost’s checklist intervention yielded a significant and sizeable decrease in rates of infection and is currently being replicated by hospitals across the U.S. and Europe.”

Evidence of a Need for Change

Sep 24, 2008• 4

By THCB Staff

The Health Care Blog regular Michael Millenson wrote a great piece recently in Miller-McCune Magazine on the necessity of practicing more evidenced-based medicine, and why it’s not happening.

Here is a powerful snippet but it’s definitely worth checking out in its entirety.

Experts believe that a stunning 20 to 40 percent of the $2.4 trillion America spends on health care in 2008 will be wasted on misuse (including harmful and fatal errors), overuse (care that’s unnecessary) or underuse ( effective care that’s not provided). If you take a midrange figure — let’s say 30 percent — you end up with $720 billion in savings. That’s enough in health care savings to pay the cumulative costs of the Iraq war (about $560 billion by mid-September 2008) and still have enough cash left over to pay for universal health care and the entire federal education budget. If you simply sent out a rebate check, it would come to some $2,100 for every man, woman and child in the country.And that’s just one year of savings.The failure to follow best practice carries a price tag in human lives, too, and it is equally enormous. Providing appropriate, effective and safe care where we know how to do it — no “medical mysteries” included — could annually prevent the deaths of hundreds of thousands of Americans in and out of the hospital and millions of injuries.