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Tag: Patient Safety

The Shocking Truth About Medication Errors

Let’s say a physician writes a prescription for Colchicine and accidentally orders “10.0 mg,” when he should have ordered “1.0 mg.” That’s a tiny decimal error, a mistake even the best doctor could make. But it can be catastrophic for the patient. The higher dose could cause Colchicine poisoning, similar to arsenic poisoning: burning in the mouth and throat, excruciating abdominal pain. Internal organs would melt away and death would likely occur within 24 to 72 hours.

The ease with which even the best doctors can make gruesome errors is why hospitals set up elaborate systems to check and double check orders before drugs are given to patients. Some hospitals are better at this checking than others. Medication errors happen all the time, an estimated one million each year, contributing to 7,000 deaths. On average there is one medication error every day for every inpatient. Let’s take a closer look at what’s contributing to these preventable errors.

Hospitals Are In The Technological Dark Ages

According to recent research, the best known way for hospitals to protect patients from errors is by adopting technology called computerized physician order entry (CPOE). The physician (or other authorized prescriber) enters orders for a patient on a computer that contains patient information such as key lab values, clinical condition, allergies, etc. The computer checks the safety and appropriateness of the order and sends it electronically to the pharmacy. In the Colchicine example, a good CPOE system would alert the physician to the misplaced decimal in the order, and the best systems would prevent the order from being written in the first place. In my mind, one of the greatest advances of CPOE is that it eliminates the need for pharmacists to decipher physician handwriting. I’ve often wondered how they do that.

The research suggests errors decline by as much as 85 percent when hospitals implement CPOE, yet the pace of adoption in the hospital industry is agonizingly slow. To jump start progress, the federal government used economic stimulus funds starting back in 2009 to incentivize hospital investment in CPOE and electronic medical records (EMRs). That improved the pace of change, but still, most hospitals are in the Dark Ages when compared to other industries like airlines or retail.

My nonprofit, Leapfrog, finds that only about a third of the hospitals that voluntarily report to our survey meet our standard for full implementation of CPOE. Even for that minority of hospitals that adopt CPOE, the system doesn’t always work as advertised. Like all technology, CPOE must be continually tested and modified. That’s not always happening.

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A Powerful Idea From the Nuclear Industry

Where health care has fallen short in significantly improving quality, our peers in other high-risk industries have thrived. Perhaps we can adapt and learn from their lessons.

For example, health care can learn much from the nuclear power industry, which has markedly improved its safety track record over the last two decades since peer-review programs were implemented. Created in the wake of two nuclear crises, these programs may provide a powerful model for health care organizations.

Following the famous Three Mile Island accident, a partial nuclear meltdown near Harrisburg, Pennsylvania in spring 1979, the Institute of Nuclear Power Operators (INPO) was formed by the CEOs of the nuclear companies. That organization established a peer-to-peer assessment program to share best practices, safety hazards, problems and actions that improved safety and operational performance. In the U.S., no nuclear accidents have occurred since then.

A more devastating nuclear incident in Chernobyl, Ukraine in 1986 spurred the creation of the World Association of Nuclear Operators (WANO), which serves a similar purpose but on an international scale. Since WANO’s inception, no severe nuclear accidents had occurred until the nuclear accident in Fukushima, Japan, caused by a devastating earthquake and tsunami in March 2011.

These programs have succeeded because their purpose and approach is very different from review processes by regulatory agencies. Instead of a punitive process that monitors compliance with minimum standards, peer-to-peer evaluations are thorough, confidential and—importantly—voluntary. They are viewed as mutually beneficial and help advance industry best practices, which are shared widely. The goal is to learn and improve rather than judge and shame. The reviews are done by experts, using validated tools and are ruthlessly transparent  yet confidential.

Peer-to-peer review has not been widely used in health care. A couple notable exceptions are the Northern New England Cardiovascular Study, which used organizational peer-to-peer review to improve the care of cardiac surgery patients, and the National Health Service in the UK, which used it to improve the care of patients with lung disease. While provider-level reviews are more common in health care organizations, they fail to capture the scale needed to achieve system-wide improvements.

At the Armstrong Institute, we have been pilot testing peer-to-peer review and early results are encouraging. We have evaluated specific outcomes, like blood stream infections; specific areas, like the operating room; and whole quality and safety programs.

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Why Doctors Should Stay Out of the Business of Building EHRs

The original Hipoocratic Oath states:

I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.

One modern version reads:

I will not be ashamed to say “I know not,” nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.

The idea here is that a doctor needs to recognize when another practitioner has a skill that they do not, and that they must refrain from “practice” when another person has demonstrable expertise in that area of practice.

It is now 2013. It is time for doctors to stop “writing their own EHR” from scratch. They need to bow out of this in favor of people who have developed expertise in the area.

I just found out about another doctor who has decided to write his own EHR, because he has not been able to find one that supports his new direct pay business model adequately. In the distant past I encountered a doctor who believed that his “Microsoft Word Templates” qualified as an EHR system. This is a letter to any doctor who feels like they are comfortable starting from-scratch software development for an EHR in 2013 or later.

You might believe yourself to be an EHR expert.

Are you sure about that? Are you sure that you are not just an EHR expert user?

This difference is not unlike your relationship with your favorite thoracic surgeon. Or for that matter, your relationship with the person who built your car. The fact that you are capable of expertly evaluating and using EHR products does not mean you are qualified to build one. Just like the fact that you are qualified to treat a patient who has recently had heart surgery or to discern when a patient might need heart surgery does not make you qualified to perform that heart surgery. Similarly, the fact that you can drive, or even repair your automobile, does not provide you with the expertise you need to build a car from scratch.

The ethical situation that you are putting yourself in by developing your own EHR is fairly tenuous. Performing heart surgery without being a heart surgeon, building and driving your own car without being an automotive engineer and a doctor coding their own EHR system from scratch all have the same fundamental problem: You might be smart enough to pull it off, but if you don’t you can really mess up another person’s life. Make no mistake, you can kill someone with a shoddy EHR just as easily as by performing medical procedures that you are not qualified for or by driving a car that is not road-safe.

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Creating Conditions for Humanity in Hospitals

Why aren’t people in hospitals more attentive to the needs of patients?

In a recent post, Dr. Ashish Jha raises this issue as he relates his own story of coming to an ED with a very painful dislocated shoulder. Unsurprisingly, prompt treatment of his pain was deferred while staff diligently completed registration, sent him for an xray, and waited for a physician to see him.

On the bike path where Jha took his initial tumble, people went out of their way to respond to his injury with attention and concern. But as he lay moaning on a gurney in the hospital corridors, waiting for an xray and not yet treated for pain, people avoided his eyes and even walked by a little faster.

What gives? Why aren’t people in the hospital more empathetic and attentive? Is this a “wonderful people, bad system” issue?

In reflecting on his experience, Jha remarks that people seem to leave their humanity at the door when they arrive at the hospital for work, and posits that we get desensitized to suffering. He notes that some workers were able to “break out of that trap,” and responded to him more empathetically when he directly solicited their help and attention.

“It is the job of healthcare leaders to create a culture where we retain our humanity despite the constant exposure to patients who are suffering,” writes Jha.

Culture change is necessary but not sufficient

Culture is important. Yes I’ll admit that I’m usually a bit skeptical when I hear of a plan to tackle a problem through culture change. In my own experience, this has consisted of leaders trying to “create culture” by describing to front-line staff  what they should be doing, and repeatedly exhorting them to do it. (And maybe giving out gold stars to those who do it.)

This, of course, is never enough. Talking the talk does not mean people start to walk the walk, especially if the walk involves a slog uphill rather than an easier stroll down a path of lesser resistance.

If we – whether healthcare leaders or  just concerned citizens who want to see healthcare improve – really want healthcare workers to demonstrate more compassion and empathy while on the job, then here is what we need to do:

  1. We should take seriously the task of understanding what might be interfering with this compassion and engagement. This means not only studying workflow, but also the behavioral psychology of individuals as well as groups.
  2. We should then be serious about creating the conditions that would allow regular human beings to reliably produce the desired behaviors.

Why it can be hard to help people in the hospital

What interferes with showing compassion and engagement? In reading Jha’s piece, I reflected on my own hospital days. Here are the obstacles that I remember, and the impact on me.

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The Perils of Multitasking

The dangers of texting while driving recently received renewed attention thanks to a public service video produced by German film director Werner Herzog.  The National Highway Traffic Safety Administration estimates that driver distraction results in approximately 3,000 deaths per year, as well as an additional 400,000 injuries.  Experts have estimated that the risk of a crash may increase by more than 20 times when texting, exceeding the risk associated with intoxication.

Texting while driving is just one example of a larger phenomenon of our age, often referred to as multitasking.  The term was coined by IBM engineers in the 1960s to refer to the ability of a microprocessor to perform multiple tasks at once.  Today the term is more often applied to human beings attempting to do more than one thing, such as simultaneously watching television and folding laundry, or answering emails while talking on the phone.  Many health professionals pride themselves on their multitasking.

In fact, however, the term multitasking is a bit of a misnomer, even in the domain of computing.  At least where one microprocessor is concerned, a computer does not so much multitask as it switches back and forth between tasks at such a high rate of speed that it appears to be doing multiple things at once.  Only more recently, with the advent of multicore processing, has it become possible for computers genuinely to multitask.

The same thing applies to human beings.  Health professionals and others who think they are multitasking are typically switching back and forth between different tasks over short periods of time.  And in most cases, multitaskers are not able to perform any of the activities in which they are engaged as well as they could if they concentrated on them one at a time.  It takes time and effort to re-focus on each task at hand, and this tends to degrade the effectiveness and efficiency of each.

To be sure, multitasking is not impossible.  In one sense, simply remaining alive requires us to multitask all the time.  Our hearts are continuously pumping, lungs exchanging gases, kidneys filtering the blood, immune system fighting infections, and all the while we are also digesting our last meal.  Add to this the ceaseless multitasking of the brain, which is monitoring the environment and maintaining our posture while simultaneously walking and chewing gum, and the complexity multiples.

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#MomInHospital

A few weeks ago, a middle-aged man decided to tweet about his mother’s illness from her bedside. The tweets went viral and became the subject of a national conversation. The man, of course, was NPR anchorman Scott Simon, and his reflections about his mother’s illness and ultimate death are poignant, insightful, and well worth your time.

Those same days, and unaware of Simon’s real-time reports, I also found myself caring for my hospitalized mother, and I made the same decision – to tweet from the bedside. (As with Simon’s mom, mine didn’t quite understand what Twitter is, but trusted her son that this was a good thing to do.) Being with my mother during a four-day inpatient stay offered a window into how things actually work at my own hospital, where I’ve practiced for three decades, and into the worlds of hospital care and patient safety, my professional passions. In this blog, I’ll take advantage of the absence of a 140-character limit to explore some of the lessons I learned.

First a little background. My mother is a delightful 77-year-old woman who lives with my 83-year-old father in Boca Raton, Florida. She has been generally healthy through her life. Two years ago, a lung nodule being followed on serial CT scans was diagnosed as cancer, and she underwent a right lower lobectomy, which left her mildly short of breath but with a reasonably good prognosis. In her left lower lung is another small nodule; it too is now is being followed with serial scans. While that remaining nodule may yet prove cancerous, it does not light up on PET scan nor has it grown in a year. So we’re continuing to track it, with crossed fingers.

Unfortunately, after a challenging recovery from her lung surgery, about a year ago Mom developed a small bowel obstruction (SBO). For those of you who aren’t clinical, this is one of life’s most painful events: the bowel, blocked, begins to swell as its contents back up, eventually leading to intractable nausea and vomiting, and excruciating pain. Bowel obstruction is rare in a “virgin” abdomen – the vast majority of cases result from scar tissue (“adhesions”) that formed after prior surgery. In my mother’s case, of course, we worried that the SBO was a result of metastatic lung cancer, but the investigation showed only scar tissue, probably from a hysterectomy done decades earlier.

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Aligning Physician Incentives Doesn’t Do It

My wife Mary and I recently got a series of early morning calls alerting us to the declining health of Mary’s mom, who was in her 90s. She died later that week. We were stricken and so sad, but took comfort that she died with dignity and good care on her own terms, and at her home in San Francisco.

Ten years ago, we received a very different early morning call, about my father.  An otherwise healthy and vigorous 72-year-old, Dad had fallen at home. Presuming he’d had a stroke, paramedics took him to a hospital with a neurosurgery speciality rather than to the university trauma center. That decision proved fatal.

A physician in Seattle at the time, I arrived the next day to find Dad in the intensive care unit on a ventilator. Dad’s head CT revealed a massive intracranial hemorrhage. Dad also had a large, obvious contusion on his forehead.

The following day, the physicians asked to remove Dad from the ventilator.  He died that night. We were profoundly devastated by his death and upset with the care he’d received.

Our family wasn’t interested in blame or lawsuits. We did, however, want answers:  Why hadn’t Dad been treated for a traumatic injury from a fall? Shouldn’t he have had timely surgery to relieve pressure from bleeding? What went wrong?

I’ve spent the last decade searching for answers, for myself and countless others, to questions about how to improve health care.  I’ve had the honor of working with many people pushing health care toward high value, at the Robert Wood Johnson Foundation(RWJF) and elsewhere.

We’ve worked hard to find solutions.  We all get it:  The health care problem is a big, complex one without silver bullet answers. Still, we’ve made incredible progress with efforts like RWJF’s Aligning Forces for Quality Initiative in which community alliances work to improve the value of their health care.

We’re searching for ways to help us all make smarter health care decisions.  We’re helping health care professionals improve and patients and families be more proactive.  We’re exploring the price and cost of care, and ways to automate health care information with technology.

And importantly, we’re working to align the incentives that health care professionals need to support and deliver great care.  We strongly believe that unless we reward great results, we won’t get them.  That means payment reform, with a focus on financial incentives for those who hunt for waste, resolve safety problems, sustain improvement, and, most of all, innovate to save more lives.

But do financial incentives to promote and reward behavior work?

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Criminal Charges for Providers Won’t Fix the NHS, Dr. Berwick

One of US President Barack Obama’s key health advisers has just published a review in the aftermath of the Mid Staffordshire hospital scandal. Don Berwick’s review is both thoughtful and reflective but one of his key recommendations – to create criminal sanctions against health staff – will not make the NHS safer for patients.

Many patients, particularly elderly ones, suffered unnecessary indignities and avoidable harm at Mid Staffordshire.

The Francis report into the crisis concluded that patients were routinely neglected by a health trust more preoccupied with cutting costs and meeting targets rather than its responsibility to provide safe care. Patients’ calls for help to use the bathroom were ignored and some were left lying in soiled sheeting or sitting on commodes for hours. Events and failings there will probably go down in history as the blackest and bleakest moment for the NHS.

When the report was published in February, the government committed to appointing a advisory group of patients to consider the various accounts of what happened and the recommendations made by Robert Francis and others. The idea was that they would distill for the government and the NHS what lessons should be learned and what changes needed to be made.

Don Berwick, who worked on the long fought for Obamacare provisions in the US, is director and co-founder of the Institute for Healthcare Improvement in Boston. He was called in by the government to reflect on the Francis report and on patient safety.

Berwick’s review makes ten recommendations including that sufficient staff are available to meet the NHS’s needs now and in the future – staff should be well-supported and able to ensure safe care at all times; quality and safety sciences and practices should be a part of the initial preparation and lifelong education of all health care professionals, including managers and executives; and leaders should create and support learning and subsequently change, at scale, within the NHS.

But most controversial is his final recommendation:

We support responsive regulation of organizations, with a hierarchy of responses. Recourse to criminal sanctions should be extremely rare, and should function primarily as a deterrent to willful or reckless neglect or mistreatment.

Berwick proposes the government creates a new general offence of “willful or reckless neglect”, applicable both to organisations and individuals. Organizational sanctions might involve removing leaders and disqualifying them from future leadership roles, public reprimand of the organization and, in extreme cases, financial sanctions – but only where that will not compromise patient care.

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Why a New Healthcare Technology Designed to Cut Costs and Increase Efficiency Probably Won’t Put Anesthesiologists Out of Work

The Wall Street Journal recently contacted me regarding an upcoming article on Sedasys, the new gadget that is supposed to be able to infuse propofol by computer while monitoring vital signs.

If you’ve read anything I’ve written previously, you’ll know that I am NOT a big proponent of technology as a means of “improving” patient care. To me, the more technology you put between the patient and the caregiver, the less medicine you’re practicing, and the more data-entry and computer programming you’re doing.

Sedasys is designed specifically to administer propofol.  Propofol is a milk-like substance that produces a range of effects from sedation to general anesthesia.  For sedation you just use less,  for general anesthesia you use more.  Its very quick onset and very quick recovery make it great for outpatient sedation.  It has to be given in a continuous drip because its effect goes away so fast.  GI docs love it because its so effective.  I suspect they also love it because propofol comes with an anesthesiologist to give it.

The only problem is the one Michael Jackson encountered: it has this pesky side effect of causing you to stop breathing.  And you can’t tell by looking at a person how much will sedate them and how much will make them stop breathing.

A little old lady with a million health problems might sedate at, say, 40 mg and stop breathing at 60 mg, while an 19-year-old could probably take 150 mg and still be fighting you.  It’s not necessarily weight-based.

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More Work Is Needed on the Safety and Efficacy of Healthcare Information Technology

If one were writing about the improvement of gastronomy in America, one would probably not celebrate “over 300 billion hamburgers served.”  But that’s very much the type of success Dr. Ashish Jha is celebrating in last week’s piece on recent US healthcare IT sales. Unfortunately, the proliferation of Big Macs does not reflect superior cuisine, and healthcare IT (HIT) sales do not equate with better healthcare or with better health. Quantity does not equal quality of care.

To be sure, Dr. Jha acknowledges the challenges of rolling out HIT throughout US hospitals. And he should be strongly commended for his admission that HIT doesn’t capture care by many specialists and doesn’t save money. In addition, Dr. Jha points to the general inability of hospitals, outpatient physicians and laboratories to transfer data among themselves as a reason for HIT’s meager results.

But this is a circular argument and not an excuse. It is the vendors’ insistence on isolated proprietary systems (and the government’s acquiescence to the vendors) that created this lack of communication (non-interoperability) which so limits one of HIT’s most valuable benefits.

In our opinion, the major concern is that the blog post fails to answer the question we ask our PhD students:

So what? What is the outcome?

This entire effort is fueled by $29 billion in government subsidies and incentives, and by trillions of dollars spent and to be spent by hospitals, doctors and others [1].

So where is the evidence to back up the government’s and industry’s promises of lower mortality, improved health and lower health care costs?

Single studies tell us little. Sadly, as many as 90% of health IT studies fail the minimal criteria of the respected international literature syntheses conducted by the Cochrane Collaboration.

In other words, studies with weak methodology or sweetheart evaluation arrangements just don’t count as evidence.
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