Tag: Patient Safety

Health care in the YouTube era

Aug 19, 2008• 5

By Bob Wachter Robert_wachter

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:

Communication 101: Shedding power imbalances to protect patients

Jul 24, 2008• 2

By Katie Fiebelkorn Westman

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.

Should a surgeon be punished for wrong-site surgery?

Jul 20, 2008• 6

By Paul Levy Surgeon

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.

Another case of wrong-site surgery: are we averting our eyes from the root causes?

Jul 10, 2008• 8

By Bob Wachter Robert_wachter

Yet another case of wrong-side surgery, this one at Boston’s Beth-Israel Deaconess Hospital. Though CEO Paul Levy does a nice job discussing the case on his blog, I’ll focus on two aspects Paul neglects: the role of production pressures in errors, and the tension between “no blame” and accountability.

First, I hope you’ll read Paul’s piece, which includes a courageous memo he and BI-D’s chief of quality Kenneth Sands sent to the entire community describing the case (within the boundaries created by HIPAA). In laying out the “how could this happen,” they say this:

It was a hectic day, as many are. Just beforehand, the physician was distracted by thoughts of how best to approach the case, and the team was busily addressing last-minute details.

Surprised? Hardly. How many days in my and your hospitals don’t look like that?

The concept of “production pressure” is an important one in safety. In a nutshell, every industry – whether it produces CABGs or widgets – has to deal with the tension between safety and throughput. The issue is not whether they experience this tension – that would be like asking if they operate under the Laws of Gravity. Rather, it is how they balance these twin demands.

When my kids were little, they loved going to the International House of Pancakes (IHOP), particularly the one about 15 minutes from my house and a few minutes from San Francisco International Airport (SFO). I personally find the food at IHOP a bit gross, but being a dutiful dad, we would trudge to the IHOP nearly every weekend.

Unfortunately, on most weekend mornings, the line extended 50 feet into the parking lot. Seeing that, I’d push the kids to move on to a decent place for a civilized breakfast. “No, dad, we wanna stay. And the line really moves fast!”

They were right. No matter how long the line, it seemed like we were seated in a matter of minutes, barely enough time to watch more than a couple of 747s fly overhead on their way to Hawaii. How did they manage this kind of throughput?

Once we sat down in the booth, the answer became clear. We were handed our menus within a few seconds. Less than a minute later, a waitress asked for our order. The food was delivered within 6 or 7 minutes. When I paused to catch my breath, the waitress was there. “Is there anything else I can get you this morning?”, she asked helpfully. Any hesitation… and the check instantly appeared, to be settled at the front register. Another family was seated the nanosecond we rose from our seats.

In other words, a business like IHOP – with its relatively low profit margin per customer – is all about production: everything is designed to get you in and out promptly. But production carries a cost: with haste sometimes come mistakes. I remember many times when our cute little syrup well was filled with four boysenberry syrups, rather than the appropriate assortment (maple, strawberry, blueberry, and boysenberry). But that seemed a small price to pay for speed.

In other words, in the ever-present battle between production and reliably getting it right, production wins at the IHOP.

As I mentioned, the South San Francisco IHOP is on the flight path of San Francisco International Airport. The tension between production and safety is particularly acute at SFO, since its two main runways are 738 feet apart (the picture at left is an actual SFO landing, with a bit of an optical illusion. But not much of one – the runways are really close).

The FAA has inviolable rules about throughput, designed to ensure that safety is defended at all costs. For example, when the fog rolls in and the cloud cover falls to 3000 feet (which happens all the time during the summer), one of the two runways is closed, not only gumming up SFO’s works but those of the entire US air traffic control system. And, whatever the weather, planes cannot land more often than one per minute.

In other words, in the aviation industry, in the battle between production and safety, safety wins. And aviation’s remarkable safety record is the result.

I’ve used this IHOP/SFO metaphor many times in speeches to hospital staff and leaders over the past few years, and usually end it by asking audiences: “In its approach to production and safety, does your hospital look more like the IHOP or SFO?” Although things have gotten a bit better over the last couple of years, the answers still run about 10:1 in favor of the IHOP.

So the fact that is was “a hectic day” is a latent error. I’m not naïve – fixing it involves setting limits on production, which slows down the works. And that costs money! Turns out, so does closing a runway. But in aviation, this is a price people are willing to pay for safety.

Will Paul, or any other bold and visionary CEO, commit to paying that price in his or her organization? Will the docs, who can care for more patients (oh yeah, and make more money) from each case? Probably not. But until we all make different choices, it is important to see the “hectic day” at Beth Israel not as a random Act of God but as a conscious choice that prioritizes production over safety. Every day. Virtually everywhere.

The other issue I found fascinating about the Beth Israel case was the discussion about the lack of safety procedures that allowed this error to occur. Again, quoting from the Levy/Sands letter,

In the midst of all this [frenzy], two things happened: First, no one noticed that the wrong side was being prepared for the procedure. Second, the procedure began without performing a “time out,” that last-minute check when the whole team confirms “right patient, right procedure, right side.” The procedure went ahead.

I’ve discussed the tension between “no blame” and accountability in a previous posting – I continue to find it one of the most interesting and difficult issues in the patient safety field. It would be good to know the context here. Was everybody (surgeon, anesthesiologist, OR nurses) distracted? Was this was the first time any of them had forgotten to perform the time out? If so, this would strike me as a “slip”, an honest mistake deserving no blame and an emphasis on designing a more reliable system.

But what if this was a surgeon who always seemed to “forget” the time out? (Believe me, they’re out there, and all of them think wrong-site surgery only happens to those other, more careless, surgeons.) To me, willfully ignoring a sensible safety rule (as I believe the time out to be, perhaps embedded the more robust WHO-style checklist, as demonstrated here) is not a “no blame” event, but rather one that screams out for accountability.

At some point, systems are people. In the old days – before the modern patient safety movement – nobody thought this way, and the fundamental problem was blaming individuals when bad systems were at fault. That was wrong, and got us nowhere in our quest to keep patients safe.

But this is now a decade later, and we do have some pretty good systems for preventing errors, systems that can always be subverted by recalcitrant providers. In such circumstances, the failure is not that of the system but that of the individual, and I believe they should be handled accordingly. This is tricky stuff, as some of the dozens of comments in response to the Levy blog, and the Boston Globe article on the case, illustrate.

Paul Levy ends his post with an eloquent and passionate bit of feedback from one of his Beth Israel-Deaconess board members:

“Protocols are meant to make procedures insensitive to distraction and busy days. These are inadequate and embarrassing excuses. The ‘culture of safety’ has not permeated the front lines. Culture of safety training, and application of advances in safety science, I believe, are critical to preventing the type of complex harm that occurs in hospitals. Not just for new staff. For everyone who wears a BIDMC badge, or is affiliated as a physician to the hospital. I know that this is a new science, and a new way of doing business, but this event might just give that leverage needed for change.

While we explore lots of ideas, one already in my mind and that of this Board member would be to make a video with the actual people – doctors, nurses, surgical techs – who were in the OR at the time to explain what they saw and felt and what they learned from the experience. While they might be in too much distress to do this right now, they might agree over time, and their doing so would create a powerful message at every orientation, at nurses and departmental meetings, and conferences… Transparency as opportunity, social marketing. It would get people talking, and thinking.”

I know the arguments against being punitive, but if this was a surgeon who habitually ignored the regulatory and ethical obligation to perform a time out, I would go ahead and produce the video as the board member suggests. The difference is that the surgeon would not only be discussing how badly he feels about the error, but also describing what he did during his one-month suspension from the OR. I’m guessing that this small addition would make the video even more memorable.

At some point, these safety rules will need teeth or they’re not rules, only suggestions. And, in many cases, suggestions won’t prevent devastating medical errors.

This is tough stuff, and I’d welcome your thoughts.

A message you hope to never send

Jul 7, 2008• 7

By Paul Levy

First, an email sent out on Thursday morning. My commentary follows.

Dear BIDMC Community,

This week at BIDMC, a patient was harmed when something happened that never should happen: A procedure was performed on the wrong body part. With the support of all our chiefs of service, we are sharing this information with the whole organization because there are lessons here for all of us.

While respecting the confidentiality of both the patient and caregivers, here are the key facts: It was an elective procedure, involving an excellent team of providers. It was a hectic day, as many are. Just beforehand, the physician was distracted by thoughts of how best to approach the case, and the team was busily addressing last-minute details. In the midst of all this, two things happened: First, no one noticed that the wrong side was being prepared for the procedure. Second, the procedure began without performing a "time out," that last-minute check when the whole team confirms "right patient, right procedure, right side." The procedure went ahead. The error was not detected until after the procedure was completed. When it was, our patient safety division was notified immediately, and they in turn took all appropriate steps including investigation, reporting and corrective action. The physician discussed the error with the patient at the first opportunity, and made a full apology. The patient is now recovering at home from the injury, which is not life-threatening.

How preventing infections rose to the forefront of the patient safety movement

Jun 24, 2008• 1

By Bob Wachter Robert_wachter

The Joint Commission just released its 2009 National Patient Safety Goals, and –- no surprise –- they focus on infection prevention. While this seems natural today, it wasn’t always so. In fact, the conflation of infection control and patient safety is one of the most surprising twists of the patient safety revolution.

The inclusion – make that dominance – of infection prevention in the safety field was anything but preordained. The IOM Report on medical errors, which sparked the modern patient safety movement, mentions the word “infections” 8 times and the word “medications” 234 times. In other words, the Founding Fathers of patient safety didn’t appear to have preventing infections in mind when they articulated the scope of the endeavor.

So how did it come to pass that infection prevention became one of, if not the, central focus of the patient safety enterprise? The first step was recognition of the importance of measurement. Without measurable rates of adverse events, there could be no public reporting, no research demonstrating improvements, no pay for performance (or, more au currant, “no pay for errors” – note that more than half of the “no pay” entities on CMS’s present and proposed list are infections), and ultimately no one who could be held accountable for progress in safety.

Why diagnostic errors don’t get any respect and what can be done about it

Jun 2, 2008• 3

By Bob Wachter

I gave a keynote yesterday to the first-ever meeting on "Diagnostic Error in Medicine." I hope the confab helps put diagnostic errors on the safety map. But, as Ricky Ricardo said, the experts and advocates in the audience have some ‘splainin’ to do.

I date the origin of the patient safety field to the publication of the IOM report on medical errors (To Err is Human). It is the field’s equivalent of the Birth of Christ (as in, there was before, and there is after). But from the get-go, diagnostic errors were the ugly stepchild of the safety family. I searched the text of To Err… and found that the term “medication errors” is mentioned 70 times, while “diagnostic errors” appears twice. This is interesting because diagnostic errors comprised 17 percent of the adverse events in the Harvard Medical Practice Study (from which the IOM’s 44,000 to 98,000 deaths numbers were drawn), and account for twice as many malpractice suits as medication errors.

What I call “Diagnostic Errors Exceptionalism” has persisted ever since. Think about the patient safety issues that are on today’s public radar screen (i.e., they are subject to public reporting, included in “no pay for errors,” examined during Joint Commission visits, etc.). It’s a pretty diverse group, including medication mistakes, falls, decubitus ulcers, wrong-site surgery, and hospital-acquired infections. But not diagnostic errors. Funny, huh?

There are lots of reasons for this. Here are just a few:

Dennis Quaid takes on hospital errors

Mar 28, 2008• 35

By Sarah Arnquist

Hospital patient safety has a new celebrity advocate in Dennis Quaid, whose twin newborns received a massive overdose of a blood thinner last year at Cedars-Sinai Medical Center while being treated for infections.

While his twins bled profusely, Quaid and his wife, Kimberly, were met by a hospital risk management team, who instead of offering an apology and explanation, provided half-truths and excuses, Quaid told hundreds of journalists Thursday at the annual Association of Healthcare Journalists Conference in Washington D.C.

The Quaids’ experience has been widely covered in the press, and he and his wife recently started The Quaid Foundation to shine a spotlight on the 100,000 people who the Institute of Medicine estimates die annually from preventable hospital errors.

"Unfortunately this tragic secret in the medical industry will continue until the medical community overwhelms a conspiracy of silence and demands public accountability,” Quaid said. "I do realize that because I’m a known person, we have an opportunity to get the word out."

Lessons From a Sad Error

Mar 20, 2008• 2

By Paul Levy

I think many people have seen this sad story of a wrong-sided kidney removal in Minnesota. We all feel the pain for this poor patient. It is difficult for us non-physicians to understand how this happens, for the pathway to the error seems remarkably clear after the fact. But, we have to understand that the actual delivery of medical care contains multiple opportunities for mistakes, and even extremely competent and well meaning doctors and nurses can find themselves in shock afterwards when this kind of thing occurs.

Here are two emails I have received on the topic which both offer useful perspectives on the matter.

First, my buddy E-patient Dave writes:

I’ve caught a couple of errors on my radiology reports, and have had them corrected. Both VERY minor compared to this. Can there be any doubt that patients need to have access to their records, as PatientSite allows, and need to be aware of their need (and ability) to read them?

Second, from one of our senior surgeons to his colleagues:

As copied below, another high profile event, to remind us how easily error can occur. In this case the consent was wrong when done in the office, and it was the only document used to confirm sidedness at the time out. As you read the article, you will note this tragedy extends not only to the patient but to the entire team, as well as the institution.

I would remind you that we had our own "near miss" here at BIDMC, which was caught by the attending surgeon, and confirmed on reviewing the images. In our case, the patient had confirmed the wrong site to the nurses, residents and fellows involved, so patients are not infallible. To best avoid this we (multiple providers) must use multiple sources of information (including the patient, exam, imaging and documentation), and we must have all OR participants agree actively that the patient ID, procedure, side and site are correct. Also as highlighted by this case, the episode of surgical care and opportunity to err starts the first time we see the patient.

Loving Our Children

Mar 14, 2008• 3

By Brian Klepper

Among its many less-noticed accomplishments, this Administration has strangled funding for comprehensive sex education. Instead, it has thrown the immense weight of the US government behind abstinence-based education, an impractical ideological approach rooted in religious zealotry and a romantic notion of social mores that no longer exists for most young Americans. In 2005 and 2006, the Bush Administration spent $170 and $178 million, respectively, more than double the 2004 expenditure, much of it allocated to mostly conservative Christian organizations, to encourage children to refrain from sex without explaining the fundamentals of contraception and sexually-transmitted disease (STD). In 2004, a Minority Staff Special Investigations report prepared at the request of Rep. Henry Waxman (D-CA) found that more than 80 percent of federally funded abstinence programs contain false
or misleading information about sex and reproductive health.