Tag: Patient Safety

Four Big Trends – Brian Klepper

Jan 16, 2008• 9

Brian Several events and trends emerged over the last year that will reverberate throughout the health care
marketplace in 2008 and going forward. While none of these dominated the trade press like some other issues – electronic and personal health records, RHIOs, the evolving labor shortage, pay-for-performance reimbursement – these manifestations of change are occurring in the marketplace as well as through policy, and are moving health care forward in fundamentally positive and far-reaching ways.

Health 2.0The most significant for the long term in terms of its capacity to change how health care works is the Health 2.0 movement, which Matthew Holt and Indu Sabaiya have played a central role in facilitating and explaining. In some ways, Health 2.0 is simply a continuation of what has come before: companies creating new value through information and connecting with customers over the Web. Health 2.0 takes this approach into every area of health care data, often driven by companies outside of or at the margins of health care, who have no financial stake in perpetuating inappropriateness and waste, and who see an opportunity to make money by rationalizing the system.

Look at How Safe [Fill in the Blank] Is by Bob Wachter

Dec 29, 2007• 2

But is it as simple as that really? Perhaps not. In the commentary that follows, Bob Wachter has a very different take on the airline analogy. Analogies are useful things, true, he argues. But perhaps not as useful as the cure-healthcare-by-adopting-model-posed-by- [ insert industry / EU member state here ] might have us believe. Who should you believe? That’s up to you. You’ll find more of Bob’s excellent commentary on quality and patient safety in the THCB archives and on his blog, Wachter’s World.

The rate of fatal domestic airline crashes has fallen by 65% in the past decade – from an amazingly low rate of one fatal accident in about 2 million departures in 1997, to a breathtakingly low rate of one in 4.5 million departures this year. Flying just keeps getting safer and safer.

Beginning with the 1999 Institute of Medicine report on medical errors, aviation has become the poster child for patient safety. In fact, it was an aviation analogy – the translation of the 44,000-98,000 deaths per year from medical errors into “the equivalent of a jumbo jet a day crashing” – that jumpstarted the patient safety field in the first place.

On the whole, I like the aviation analogy, because it energizes us and helps illustrate the need for certain safety-oriented practices, such as standardization, simplification, simulation, teamwork training, and effective reporting systems and regulations. It is also uniquely accessible: who would ever fly electively if a big plane went down every day in the U.S.? Yet hundreds of thousands of people check into hospitals and clinics electively daily.

But lately, I’ve sensed gathering pushback against the aviation analogy – as well as against analogies from other industries. “This has nothing to do with us,” I hear from colleagues sometimes. “Healthcare is so different.” And they’re partly right. For example, we have learned that dampening down authority gradients on a med-surg ward is orders of magnitude harder than doing so in a cockpit. Here’s why: to prevent another Tenerife disaster (the horrific 1977 runway incursion/collision of two 747s, ostensibly caused when the flight engineer – who suspected there was a large airplane blocking the way – felt uncomfortable speaking up to his boss, the pilot), aviation had to transform its culture.

HOSPITALS: Dennis Quaid’s Kids – Are VIPs Safer? By Bob Wachter

Nov 26, 2007• 6

Robert_wachter Robert Wachter is widely regarded as a leading figure in the modern patient safety movement. Together with Dr. Robert Goldman, he coined the term "hospitalist" in an 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."
The Entertainment Blogosphere was atwitter this week with the story
of actor Dennis Quaid’s twin
newborns, who reportedly received a
1000-fold heparin overdose at Cedars-Sinai Medical Center in La La
Land. Cedars’ Chief Medical Officer Michael Langberg may win this
year’s Oscar for fastest public apology – having learned the lesson
from the 2003 Duke transplant error, where the hospital stonewalled for a week or so, adding chum to the media feeding frenzy.

The
error came during heparin line flushes, when a 10,000 units/ml solution
of heparin was mistakenly substituted for the intended 10 units/ml
solution. Although the cases required pharmacologic reversal of the
anticoagulant effect, thankfully there were no bleeding complications.

These cases come on the heels of last week’s report
out of Dallas that the state-supported UT-Southwestern kept an “A-list”
of potential donors and assorted bigwigs. Apparently, when these folks
come to the hospital or clinic, they may get a personal greeting, a
preferential parking spot, perhaps even an escort to their appointment.
My friends at Health Care Renewal, who chronicle and condemn healthcare’s corporate influences, were shocked. Shocked!

I’m
not. 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.

When is a Medical Error a Crime? by Bob Wachter

Nov 16, 2007• 17

Bob Wachter is one of the nation’s leading experts on medical safety and one of the pioneers of the hospitalist movement. And now he’s descending into the mire of blogging! So we’re pleased to cross post one of the more recent pieces from his (relatively) new blog Wachter’s World.

Robert_wachter The first commandment of the modern patient safety movement was “Thou Shalt Not Blame.”
Old-Think:
errors are screw-ups by “bad apples,” and can only be prevented by some
combination of shaming and suing the doctor or nurse holding the
smoking gun. New-Think: errors represent “system problems;” any
attempt to assess blame will drive providers underground, inhibiting
the free-flow of information so crucial to error prevention. Like
most complicated issues in life, the truth lives somewhere between
these polar views. In the main, the “no blame” view is right – most
errors are committed by good, hardworking docs and nurses, and
finger-pointing simply distracts us from the systems fixes that can
prevent the next fallible human being from killing someone.Yet,
taken to extremes, the no blame argument has always struck me as both
naive and more than a little PC. Anyone who has practiced for more than
a month can name docs and nurses who they would never want caring for
their loved ones. And what about the substance-abusing nurse, the
internist who doesn’t keep up with the literature, the
retractor-throwing surgeon, or the provider who refuses to follow
reasonable safety rules. If nobody is ever to blame, who is
accountable?