Medical Errors

QUALITY: The Bottom Line is Still Patient Safety. And We're Still Waiting

Joanne Kenen — Tue, 17 Nov 2009 19:05:00 -0500

With all the talk of financing and mandates and public options, it's important to make sure the essentials -- that patients are helped, not harmed, by health care -- don't get overlooked. Consumers Union's Safe Patient Project held a daylong event here in DC today to help us keep that in mind.

Roughly 100,000 patients die a year from medical errors and about another 100,000 die of infections acquired in health care settings. "The status quo is not acceptable," Art Levin, director of the Center for Medical Consumers, told the forum.

Consumers Union last May marked the 10th anniversary of the Institute of Medicine's landmark "To Err is Human Report" with a report of its own called "To Err is Human - To Delay is Deadly" (Here's what we wrote about it at the time). The bottom line: not a lot of progress.

The event today highlighted some achievements; the health reform legislation does take some important steps to improve safety and quality. It also sheds a rather depressing light on how much remains to be done.

On the plus side, the House bill has new requirements for hospitals and ambulatory surgical centers to report infections, and the infection rates will be made public. The Medicare policy of not paying hospitals for treating certain avoidable infections will be extended to Medicaid. Both the House and Senate bills start to address high hospital readmissions (often avoidable when care is optimal), and both include an array of test programs and studies designed to improve care quality.

But safety advocates have set the bar higher for transparency -- they want public reporting of medical errors, not just infections, publicly accessible quality data banks, more safety training for doctors and nurses. And they are still waiting.

The CU event also showcased some excellent reporting on patient safety. The Pro Publica series by Charlie Ornstein and Tracy Weber on incompetent -- make that dangerous, nurses -- staying on the job in California got a fair amount of attention, but if you missed it, here's your chance. (Read the follow up reports too.) And the Hearst papers have an ambitious national reporting project called Dead by Mistake, and it's pretty shocking. Among the conclusions: in the decade since the IoM report, as many as two million Americans have died of preventable medical mistakes. And too often, health care providers have responded with secrecy, not transparency. And that in many ways, the problems are just getting worse.

QUALITY: Safety Is Not An Accident

Joanne Kenen — Wed, 28 Jan 2009 14:47:00 -0500

Robert Wachter, MD, a respected patient safety expert, has a long but fascinating dissection of the recent US Airways landing in the Hudson River, where everyone survived, versus the worst crash ever, when KLM and Pan Am jets crashed on the runway in Tenerife in 1977 . Safety, we conclude after reading his account of how training, culture and technology have changed in the intervening years, is not an accident. He writes:

What does this have to do with health care? How often do we and our teams drill on management of dangerous situations (code blues, crash C-sections, airway problems, even complex patient transports)? Close to never. How much do we use simulation to practice our responses to these emergencies before they happen? Except for a few early adopters, rarely. How many of us have gone through rigorous teamwork training to learn to better communicate with our "cabin mates" during times of stress? Remarkably few. How often do we need to demonstrate our continued competency in our specialty? For most board certified physicians, about every 10 years (up from "never" 20 years ago). And how well do we learn from our errors? Well, never mind.As we prepare the ticker tape for [US Air] Captain Sully (as we should), we should recall that his success was largely a product of his training and a series of actions taken in commercial aviation—steps that made the Swiss cheese less "holey" and created enough overlapping layers to minimize the chances that an error or safety hazard (in this case, some foolish birds) would lead to tragedy.

...We need to continue to work, as aviation has for the past generation, to train our "pilots" to become Sullys. We in health care are flying over some pretty cold rivers, each and every day.

We've been writing a lot about cost and coverage and the economy recently (for obvious reasons) but it's worth remembering that we aren't just interested in covering people. We want to cover them in a reformed, modernized, streamlined, cost-efficient, high quality, compassionate system. You'd think that would be easier than landing a plane safely in a river, wouldn't you....

QUALITY: These Statements Have Not Been Evaluated by the FDA

Paul Testa — Mon, 24 Nov 2008 20:48:00 -0500

Can we interest you in some unapproved drugs?

Medicaid is interested. So is the FDA. And Senator Chuck Grassley (R-IA). It seems that from 2004 to 2007, Medicaid spent nearly $198 million paying for prescription drugs that had not gone through FDA safety and effectiveness reviews, according to analysis of federal data by the Associated Press.

Bringing in the bigger picture, the AP notes:

At a time when families, businesses and government are struggling with health care costs and 46 million people are uninsured, payments for questionable medications amount to an unplugged leak in the system.

The FDA estimates that unapproved drugs account for 2 percent of all prescriptions, or about 72 million scripts per year. (Informative FDA video with great sound track here) Many of these drugs provide little or no benefit to the patient. Some are potentially harmful, even deadly, contributing to the some 1.5 million Americans, killed sickened or harmed by preventable medication errors each year.

How did we get here?

In 1962 Congress passed a law requiring the FDA to test the safety and effectiveness of all new drugs entering the market. But today's class of unapproved drugs were already on the market, and were "grandfathered" in, allowing their continued sale today.

The concern over unapproved drugs spiked in the 1980s, when E-Ferol, a high potency vitamin E injection, was linked to the deaths of some 40 premature babies. Since then the FDA has taken steps to remove unapproved drugs from the market and encourage their manufacturers to adhere to FDA guidelines. Critics, as the AP notes, suggest this case-by-case basis is not enough. Senator Grassley has long been outspoken on the issue, last year asking the Office of the Inspector General of HHS to investigate.

Does the FDA have bigger fish to fry? Maybe. But the AP's findings provide further evidence of the lack of knowledge and coordination that exists in our fragmented system. Weeding out old cough remedies from the 1920s is just one of the benefits from the clinical and comparative effectiveness data that a more integrated health care system would provide. (And of course some of these old cheap drugs, once properly reviewed, could turn out to be better options than their expensive new cousins) After all, when you're recovering from the hantavirus, you'd like to know what's snake oil and what's safe.

QUALITY: A Stroke of "Genius" for Health Innovators

Joanne Kenen — Tue, 23 Sep 2008 17:55:00 -0400

This year's MacArthur "genius" grants included three extraordinary physician-innovators. All three are practicing physicians, taking care of patients. All three are also showing us how we can improve the whole system, not just for a handful of patients lucky enough to have exceptional doctors. Diane Meier is a pioneer in palliative care, illustrating how we can dramatically improve care for the seriously or terminally ill—and save money while we're at it. Regina Benjamin provides primary care to the poor in unbelievably difficult conditions in rural Alabama. Peter Pronovost is a critical care physician who has shown hospitals simple, inexpensive ways to prevent lethal infections. What's really phenomenal—and different—is that if you try to talk about some of these concepts to policymakers in Washington, at least some of them will know what you are talking about. That wasn't as true just two or three years ago, and I think it shows a growing awareness that health reform has to do more than cover people. It has to cover people in a health care system that is both more efficient and more compassionate.

I got to know Diane Meier though the reporting I've done in the last few years on palliative care. She is a geriatrician and palliative care physician at Mount Sinai in New York and the director of the Center to Advance Palliative Care. (We've blogged about palliative care here, here, here and here, about the potential money palliative care can save here, and I've written about Meier here and here.) CAPC is an interesting model: It promotes research, but it also teaches doctors and nurses and social workers the nuts and bolts of palliative care. Not the medical aspects— there are other CME opportunities to learn about fentanyl vs morphine etc. At CAPC conferences and seminars (I first met Diane at one in Chicago in 2006) she teaches medical staff how to design a business model for palliative care, how to get hospital CEOs and CFOs on board, how to make arcane Medicare billing rules work, more or less, to their advantage. She even shares fund-raising tips {"Wear pearls," she tells the women in her audiences.") But I've also seen Diane, pearl-free and in sensible shoes, spend more than an hour listening to just one elderly patient with hip pain, or explaining to oncologists in training that chemotherapy and opiates aren't the only things their patients need. Empathy, patience, emotional perception and knowing how to work the system are also part of the arsenal.

I met Dr. Regina Benjamin only once but she's not easy to forget. She took the time to travel to Missisippi in the spring of 2007, about 18 months after Hurricane Katrina, to talk to a small group of health care journalists. We weren't writing about her that day, we were just learning from her, and she was fine with that. Dr. Benjamin is a family physician in the tiny shrimping community of Bayou La Batre in southernmost Alabama. It is racially and ethnically mixed, including an influx of Vietnamese who were drawn to its shrimping fleet, probably the only thing in the fictional home of Forest Gump that was familiar to them. (I don't have my notes from that trip handy, but I'll share this post with colleagues and Kaiser Family Foundation staff who were on that trip with me. If they remember anything that I've overlooked, I hope they'll comment.) News articles about Dr. Benjamin's award point out that her clinic was destroyed by Hurricane Katrina, but she rebuilt it—only to have it burn down just as they were ready to reopen. What the articles omitted is that she had to rebuild as well less than a decade earlier, after Hurricane Georges in 1998. Each time, the grateful community rallied around to help her, as she has helped them, putting the bills on her own credit card when she had no other choice. When her clinic is out of commission, she treats patients out of her beat up old pick-up truck (if this sounds like a story of inspiration ready for Readers' Digest, you're right.) She also finds time to serve on all sorts of health-related and nonprofit boards, and in her "spare" time, she mentors and teaches younger doctors how to provide quality care to underserved communities in rural America.

You may have read about Dr. Peter Pronovost from Johns Hopkins in Atul Gawande's New Yorker piece last fall, and my colleague Paul Testa has written about his infection-control work too. Just yesterday—and we think this is a coincidence but who knows—the House Oversight Committee released a report about how hospitals were (or more often were not) preventing bloodstream infections from central lines (or central venous catheters.) It concluded that if all state hospitals were to use the simple checklist that Pronovost helped develop, more than 15,000 lives and $1.3 billion would be saved each year. While other guides for infection-control have 111 steps. Pronovost's has five, and they are rich in common sense but very low in cost:

Handwashing;
Full draping of the patient;
Cleaning the skin with proven cleansers;
Avoiding catheters in the groin if possible; and
Removing catheters as soon as possible.

If they can work in strapped Detroit hospitals, they can work anywhere.

(Update: See also our Sept 24 post on Dr. Wafaa el-Sadr, an innovator in public health and HIV/AIDS)

QUALITY: Making the (Wrist) Band Work For Patient Safety

Paul Testa — Wed, 03 Sep 2008 21:16:00 -0400

In 2004, Lance Armstrong revolutionized wristwear awareness with the yellow silicone Livestrong wristbands. Now, hospitals in Alabama hope to raise awareness of patient safety by adopting a standardized system of color-coded wristbands for admitted patients.

Starting in October, no matter what hospital in Alabama a doctor or nurse is working in, a given color wristband on a patient will mean the same thing:

Red? Check for allergies.
Yellow? The patient is at risk for falling.
Neon bangles? Call the 1980s. (Just kidding.)

The program is modeled after an initiative in Arizona and more than 20 states have taken similar steps, according to Montgomery Advertiser. It reflects a growing emphasis in health care on patient safety and the potential impact of simple changes. Let's stress that word simple. Think of how much easier it is for a doctor who may rotate through several hospitals to remember and internalize one set of color signals that could make a huge difference.

We've written frequently on the cost of medical errors and the potential ways to improve health care quality (and at same time reduce unnecessary costs). The Institute for Healthcare Improvement is a major champion of this cause, and our colleague Tom Emswiler did a series of excellent posts from IHI's recent conference: "Achieving the Triple Aim: The Simultaneous Pursuit of Excellent Health, Ideal Care, and Controlled Costs." (here, here, here, and here)

Each year 98,000 people die because of preventable medical errors, according to estimates by the Institute of Medicine. Standardizing the color of bracelet or checklists that promote hand-washing and infection control may seem insignificant, but in our crowded, complex health care system they can be lifesavers.

QUALITY: The Unintended Consequences of Never Events

Joanne Kenen — Thu, 21 Aug 2008 18:44:00 -0400

Changing anything as complex as health care can lead to unintended consequences and perverse incentives, and some health care providers see the "Never Event" initiative as chock-full of them. (Here's an article from Health Leaders Media, I'll come back to it in a moment.)

The "Never Event" policy means that Medicare will stop paying for certain avoidable errors; some states and major private insurers are following suit. Patients wouldn't have to pay themselves for the extra care, but the hospital wouldn't get reimbursed for the cost. CMS, the agency that runs Medicare, has announced one set, effective this October, and has proposed a second set for 2009 which is still being evaluated and going through the rule-making process. Medicare based its decisions on work by the National Quality Forum (NQF). We'll add both lists to the bottom of this post.

If you peruse blogs and online forums of doctors and nurses, you'll find a lot of complaints about the policy. Check out this thread on WhiteCoat Rant. Or this one by a nurse who calls himself "Country Rat" who argues that "complications are the result of the patient being sick." We haven't come across anybody defending egregious actions like operating on the wrong patient or wrong body part—certainly even the biggest CMS-hater agrees that should be a "Never Event." (please don't tell us that we just haven't looked hard enough.) Some of the nervous docs and nurses may be applying the CMS rules too broadly. Not all blood sugar problems are "Never Events," for instance, although severe ones may be in some circumstances. Some of the worries are quite reasonable; nurses for instance who wonder about whether it's realistic to raise the quality bar without addressing nursing shortages. If I were taking care of 10 extremely sick patients in the middle of the night, I might be asking myself the same questions. We've seen questions raised by clinicians about the proposal to add delirium to the list, or Legionnaire's disease, which we expect will be thrashed out or clarified in the rule-making process.

Some of the reaction, however, can be troubling. It's not comforting to know that some of the people who take care of us regard these conditions as immutable facts of medical life. Some balk at classifying MRSA infections as avoidable. But antiobiotic resistant infections can be avoided, or at least made far less frequent, as the Safe Care Campaign among other groups can show us. (For more info, see the Superbug blog by my friend Maryn McKenna, who guest posted for us last week). It's disturbing, too, when health care providers contend that pressure sores (aka bed sores or decubitus ulcers) are inevitable. Dr. Joanne Lynn, one of the nation's leading geriatricians and experts on end-of-life care, just wrapped up a stint at CMS where she worked on quality issues, and pressure sores were a key task for her. They made progress (though that particular initiative was nursing homes, not hospitals) through an innovative team approach reported in the Journal of Geriatrics, the New York Times, and the American Health Quality Association.

The Never Event policy has two goals. One of course is patient safety. The other is cost. Mistakes cost billions. Preventing mistakes can cost money too but it's money well-spent and it should end up saving money overall. Or will it? That brings us back to that Hospital Leaders article and the perverse incentives. Some of the hospital executives quoted in the article said the new rules wouldn't make much difference in how they operated, except perhaps some modest increase in personnel for more careful documentation and consistent coding when patients are admitted. But Dr. Bob Wachter, chief of the division of hospital medicine and the medical service at the UCSF Medical Center, sees a whole new kind of defensive medicine, with the hospitals adding extra steps to protect themselves from Medicare payment policies. If they can show that a patient came in with a "Never Ever" condition, from home or a nursing facility, they can't be accused of letting it develop in the hospital. Hence lots of extra pushing and probing to see what's there and who to blame it on. (Some infection screening may be a good idea -- but he's talking about more extensive screening on more patients.)

"It's going to lead at best to wasteful spending and at worst to clinically inappropriate care to make sure that [the patient's] chart looks good," Wachter was quoted as saying. More tests squander resources, and aren't necessarily good for the patient. We here at New America see his point. But we also think the Never Event approach is a valid one. There may be bumps, problems, adjustments, and Medicare—as well as hospitals—may have to make some tweaks and revisions, as they do to many new programs. That doesn't mean the basic goals—protecting patients, paying for value, spending wisely—aren't worth pursuing. Who knows how many pressure ulcers won't develop, how many infections will be thwarted, how many pneumonias will be avoided. Maybe, Country Rat RN's plaint not withstanding, being sick is complication enough without all those extra complications.

As promised, here's the list:

Year 1:

Object inadvertently left in after surgery
Air embolism
Blood incompatibility
Catheter associated urinary tract infection
Pressure ulcer (decubitus ulcer)
Vascular catheter associated infection
Surgical site infection—Mediastinitis (infection in the chest) after coronary artery bypass graft surgery
Certain types of falls and trauma

Proposed for year 2:

Surgical site infections following certain elective procedures (including bariatric surgery)
Legionnaires' disease (a type of pneumonia caused by a specific bacterium)
Extreme blood sugar derangement
Iatrogenic pneumothorax (collapse of the lung)
Delirium
Ventilator-associated pneumonia
Deep vein thrombosis/Pulmonary Embolism (formation/movement of a blood clot) after total knee replacement and hip replacement procedures
Staphylococcus aureus septicemia (bloodstream infection)
Clostridium difficile associated disease (a bacterium that causes severe diarrhea and more serious intestinal conditions such as colitis)

COST: What's the Best Way to Fight Those Nasty MRSA Bugs?

Health Policy — Thu, 14 Aug 2008 15:00:00 -0400

We usually write about health policy, not microbes and science, but sometimes they intersect. MRSA—as the stubborn pathogen methicillin-resistant Staphylococcus aureus is known—is a case in point. Hospitals are debating how to control MRSA, states are debating what policies or mandates will best spur progress, and insurers are increasingly saying that they regard hospital-acquired MRSA infections as an avoidable medical error—and they won't reimburse hospitals for the extra costs of treating it. So we asked Maryn McKenna, a health journalist and author of a book on the CDC and the forthcoming book SUPERBUG: The Rise of Drug-Resistant Staph and the Danger of a World Without Antibiotics to guest blog and catch us up.

Stopping the spread of the stubborn pathogen methicillin-resistant Staphylococcus aureus—MRSA, for short—is one of the most contentious topics in infectious disease policy right now. A small sample of the, umm, highly divergent views on the subject recently filled up the letters and pages of the Journal of the American Medical Association.

(Simple background review: MRSA is a subtype of an extremely common bacterium that, over 40+ years, has become resistant to a wide array of antibiotics used against it. From the late 1960s to the late 1990s, it was primarily a problem within hospitals, where it caused ferocious infections in vulnerable patients. In the 1990s, a community strain arose separately, with fewer resistance factors but greater virulence and an enhanced ability to spread among the apparently healthy. That's the strain responsible for widely reported sudden deaths of children from pneumonia and bone infections.)

Community-associated MRSA has grabbed the public's attention over the past year, but hospital-acquired MRSA remains a huge problem—so much so that the Center for Medicare and Medicaid Services has proposed treating it as a medical error and declining to reimburse hospitals for the extra care that must be given to a patient when it occurs.

Within health care, there is vociferous debate over how to control MRSA in hospitals. Because MRSA can live on the skin, nostrils and other body sites for a long period of time before causing an infection—either in the person colonized by the bug or in someone else who acquired it from the colonized person—many hospitals espouse a program of checking new patients who are most likely to be carriers, including patients in high-risk units such as ICUs, new admits from long-term care facilities (i.e. nursing homes), and people who have had MRSA infections in the past.

But a small set of institutions are pursuing a more aggressive program, variously called "active surveillance and testing," "universal screening" or "search and destroy," that checks every inpatient for MRSA colonization and confines them to isolation until the bug has cleared.

"Search and destroy" was the topic of an important JAMA paper and editorial last March that decided the effort wasn't worthwhile. (A simultaneously published paper in the Annals of Internal Medicine completely disagreed.) The five letters in the recent JAMA tear the topic apart, examining definitions, methodology, cost-effectiveness, adherence to infection control and more. The most intriguing suggests that "search and destroy" contains a hidden agenda: that if hospitals can demonstrate patients were carrying MRSA on admission, they may be able to make a case for any subsequent infections not being their fault—and escape the lowered reimbursement rates that CMS proposes.

QUALITY: Getting the Party Started on Payment Reform

Paul Testa — Thu, 07 Aug 2008 20:25:00 -0400

Forget star-studded parties in the Hamptons. The most-talked about events in health policy these days are so-called never events—serious preventable medical errors, such as operating on the wrong patient or body part. And if policymakers and payers have their way, never events will someday be non-events.

Medicare helped get the party started when it announced that come October it will stop paying for a series of preventable medical errors that result in serious consequences to patients. Private insurers across the nation have followed suit, and BlueCross and Blue Shield of Illinois, the state's largest insurer, has joined the party, according to the Chicago Tribune.

The Tribune's Bruce Jasper lays out the issue and explains the goals:

The idea is that forcing hospitals to absorb those costs will create an incentive to improve quality of care in a business where money typically rolls in regardless of patient outcomes and customers often feel lost in a complex, impersonal system. [...]

Never events are rare, and insurers say they typically aren't billed for the most egregious errors, such as removal of the wrong limb. Those errors often lead to malpractice suits instead. But there are many other instances in which patients or their employers end up paying more money because of hospital error, such as a re-do of a botched surgery or a longer hospital stay because of an infection.

The example of never events is interesting, because it suggests that Medicare can be for payment policy what Jackie Onassis was for Chanel jackets and neutral hues—a trend setter. If Medicare can jumpstart a movement to refuse payment for serious medical errors, imagine what it can do for the payment and practice of medicine as a whole. As the single largest purchaser of medical services in the U.S., Medicare offers one potential way of moving to a system of payment based on the quality of outcomes, not the quantity of services.

Now that's a party we'd lke to attend.

QUALITY: Making the Business Case for Preventing Medical Errors

Paul Testa — Wed, 30 Jul 2008 13:44:00 -0400

To err is human, and when it comes to medicine, it's especially costly.

Up to 98,000 Americans die each year from preventable medical errors and, according to a new study published Monday in the journal Health Services Research (abstract) preventing mishaps during or after surgery could not only save patients from harm but also save the health care system close to $1.5 billion a year.

Using indicators of patient safety developed by AHRQ, the authors examined insurance claims data for seven categories of preventable adverse medical events—things that shouldn't happen if established guidelines of care were followed. They also looked at data over a three-month period to more accurately reflect the post-discharge costs of readmissions and deaths that occurred as result of a preventable error during or following the initial surgery.

Compared to patients who received appropriate care, the additional costs for patients who experienced the following medical errors were particularly dramatic:

Acute Respiratory Failure—$28,218 (52 percent more)
Infections due to medical care or sepsis (blood poisoning)—$19,480 (42 percent more)
Nursing Sensitive events such as hip fractures or pressure ulcers—$12,196 (33 percent more)
Metabolic Problems like kidney failure or uncontrolled blood sugar—$11,797 (32 percent more)
Pulmonary and Vascular Problems such as blood clots and embolisms—$7,838 (25 percent more)

Reducing medical errors is an obvious goal for many reasons, but the authors of the study stress that their findings help to build the business case for health reform. The authors argue it's the purchasers who have the most leverage to encourage hospitals to invest in patient safety. As this study shows, they also have a lot to gain. Medicare and some private insurers have already announced they will stop paying for so-called "never events,"—things like operating on the wrong side or even the wrong patient.

Better quality care can be cheaper care, but real improvements in quality will only come from comprehensive reforms that provide incentives for better care and not just more care.

To err is human, but sustainable health reform, now that's divine. There will always be a risk of medical errors, but hopefully quality health care experiences like our colleague Joanne Kenen recently described can become the expectation of care rather than an exception to the rule.

(Hat tip to J.R. whose Larry David-like tenacity got us a hard copy of the HSR study from the computer labs of Georgetown with only one call to IT and one trip to the student ID office.)

QUALITY: To the Lighthouse of Reform Through Evidence-Based Design

Paul Testa — Mon, 28 Jul 2008 22:15:00 -0400

Who said English Lit had nothing to do with health reform? When it comes to stopping the spread of deadly hospital-acquired infections having a room of one's own (although not necessarily a room with a view) can make a big difference, according to today's Los Angeles Times.

The CDC estimates that hospital-acquired infections take close to 100,000 American lives each year. Using the principles of evidence-based design, Bronson Methodist Hospital in Kalamazoo, Michigan reduced infection rates by close to 11 percent by switching from a multi-bed room facility to private rooms. Other design decisions that could improve care include:

Ventilation systems and air filters to keep infections from circulating through the hospital
Easily cleaned, nonporous surfaces (MRSAs love shag carpeting, but hate antimicrobial linoleum)
Lots of sinks, with separate facilities in a room for patients and health care workers

The article highlights some impressive results from such evidence-based designs (many of which have been incorporated in the American Institute of Architects' guidelines for the design and construction of health care facilities). For example, one hospital in Indiana saw medication errors drop by 67 percent when it changed its coronary ICU to single-bed rooms.

More examples can be found at The Center for Health Design's Pebble Project, which highlights designs from various health care providers with the goal of generating a ripple effect of innovation throughout our health care system. The Barbara Ann Karmanos Cancer Institute, in Detroit, MI reduced medical errors 30 percent by better organizing medications and supplies, standardizing visual cues, and reducing noise levels. (We wrote recently about a recent study of how nurses spend their time that also called for better organization of supplies and equipment.)

The voyage out to a more efficient health care system may still be a bit long but small changes, from the floor plans of an ICU to the placement of oximeters can have a big impact. Now, if more medical providers could take E.M. Forster's advice and only connect! To health IT, that is.