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
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.
Gina Kolata’s must-read article in last week’s Science Timespoints 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.
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.
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?
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?
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.”
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.
August 11th was the 2nd anniversary of the epic implosion of George Allen’s presidential campaign, the first defeat at the hands of YouTube. Two recent videos of unattended patients dying in ER waiting rooms leave me wondering whether health care has also entered the YouTube era.
Remember the George Allen fiasco? A 20-year-old Indian-American named S.R. Sidarth, working for Allen’s opponent Jim Webb, was filming an Allen campaign stop in Breaks, Virginia. Twice, Allen pointed to him and called him “Macaca,” a racial slur meaning “monkey.” Once the video hit YouTube, it went completely viral (this clip, one of many, has been viewed 350,000 times) and Allen’s promising political career was toast.
What does this have to do with health care? In the past 18 months, two powerful, highly troubling videos have surfaced of patients being left to die in ER waiting rooms. The first, in May 2007, involved a woman named Edith Rodriguez. Rodriguez began vomiting blood while waiting outside the King-Drew ER, and soon collapsed. Rodriguez’s husband called Los Angeles’s 911 system, but got nowhere. Then someone else in the waiting room called:
Katie Fiebelkorn Westman is a registered nurse at an acute care hospital in the Minnesota Twin Cities. She is working toward a clinical nurse specialist degree, focusing on improving patient care quality.
The Joint Commission’s recent sentinel event alert on the detrimental affects of ineffective communication between caregivers prompted me to examine the communication I see daily in the hospital.
The dearth of effective communication skills is not limited to the health care profession — we just have bigger consequences when we get things wrong. Someone in another profession may run a report incorrectly and be annoyed to have to redo it, but in health care, we can take off the wrong body part, give the wrong medicine, or send someone home with the wrong discharge instructions.
These mistakes are big deals. We need, as healthcare providers, to respect each other, our different points of view, and learn how to talk.
During these couple of weeks following our wrong-side surgery, a number of people
have asked me if we intend to punish the surgeon in charge of the case, as well as other people in the operating room, who did not carry out the expected time-out procedure.
My initial and immediate reaction has always been, "No, these people have been punished enough by the searing experience of the event. They were devastated by their error and distraught to think that they could have participated in an event that unnecessarily hurt a patient. The surgeon immediately reported the error to his Chief and to me and took all appropriate actions to disclose and apologize to the patient, as well as participate openly and honestly in the case review."
This reaction was supported by one of our trustees, who likewise responded, "God has already taken care of the punishment." But another trustee said that it just didn’t feel right that this highly trained physician, "who should have known better," would not be punished. "Wouldn’t someone in another field be disciplined for an equivalent error?" this trustee asked.