Medical Errors

If you ran a summer camp that never reported the vast majority of times that you hurt one of your campers, you'd probably be shut down, arrested, or worse. The situation would be similar if a restaurant repeatedly made customers sick, or if a skydiving business habitually gave people the wrong parachutes.

Why, then, do hospitals only report about one in seven of the hundreds of thousands of medical errors, infections, and other adverse events that harm patients every year? And why can they get away with it?

That's a crucial question posed by Shannon Brownlee's most recent piece on TIME Ideas: An American Hospital: The Most Dangerous Place? Brownlee addresses the recent report from the US Department of Health and Human Services, which catalogued problems with the reporting system for medical errors and other patient harm. She argues that the reporting problems are only a piece of a larger quality and safety problem, and that hospitals need to move quickly to adopt checklists and other types of safety mechanisms:

"Some hospitals have made great strides in reducing errors and infections using — you guessed it — checklists. About 10 years ago, Dr. Peter Pronovost, an intensive-care specialist at Johns Hopkins Hospital in Baltimore, and a team of colleagues put together a series of checklists for some of the most common procedures performed in the intensive-care unit. For example, they created a list of steps for how to put in a central line — a tube for delivering medication directly into a vein in the patient’s chest — in a way that reduced the risk of infection. They made a checklist to prevent patients on a ventilator, or breathing machine, from contracting pneumonia. When Pronovost was given a grant to get every ICU in the state of Michigan to use just three of his checklists, the result was 1,500 lives saved and the state of Michigan saved $100 million."

You can read the full story here: http://ideas.time.com/2012/01/09/american-hospitals-the-most-dangerous-place/

We don't often post raw links or pictures without commentary, but the last few weeks have involved a few great ones that we couldn't pass up.

First: via the new Washington Post Wonkblog (congrats on the new site, guys!), Dr Seuss explains the medical arms race in the video to the right! (Watch it fullscreen--it's worth it!)

In March, Fast Company magazine recently released their “10 Most Innovative Companies in Health Care” list for 2011. Somehow the article about it popped up on our Google Reader last week, so we decided to take a look. The list didn't seem to get much attention the first time around, and it's worth taking another look now. 

The list ranges from industrial titan GE, recognized for their vastly miniaturized handheld ultrasound machine, to the Cleveland Clinic, for “rethinking the entire hospital experience.” Nice to see companies on the list who are focusing on making medicine better, rather than simply making it more technologically advanced.

The issue of patient safety is poised to take center stage in the discussion of health care system improvement. One week after the journal Health Affairs released a landmark study indicating adverse medical events are even more common than previously believed, the Centers for Medicare and Medicaid Services (CMS) have launched a multifaceted assault on the problem of medical errors in America. The issue is yet another vital piece of the cost and quality puzzle that the industry must resolve to combat the unchecked rise in national health expenditures.

This post was originally published in iHealthBeat, www.ihealthbeat.org.

HHS recently released a package of regulations clarifying the definition of achieving "meaningful use" of electronic health record systems. Eligible providers and hospitals must meet the meaningful use criteria to qualify for government incentives and bonus payments for the adoption of EHR systems. The regulations signify a milestone accomplishment in moving forward our nation's commitment to the universal adoption of EHRs.

Each day, the American health care system conducts more transactions than the New York Stock Exchange, most of them on paper and at risk of human error. The Institute of Medicine estimates there are between 44,000 and 98,000 deaths attributed to medical errors each year, andwhile not all errors can be precluded by the adoption of EHRs, there is no question that standardized, interoperable systems will move us in the direction of improved quality and efficiency and reduced errors and waste.

Over the summer, Bob Wachter wrote about "the non-scalability of charisma," how hard it is to make change for the better in health care, even relatively simple and proven steps such as implementing a checklist to reduce infection. We followed up with some thoughts about why it might not be quite so bleak -- because health reform is changing some of the incentives (not as many as we would have liked, but some), states are stepping up reporting requirements and transparency, and CMS is in very good quality-inspiring hands these days.

But Katherine Garrett, a New York based health quality expert, who happens to be one of  blog editor Joanne Kenen's oldest friends (and who if Joanne's memory serves was the first person many years ago to tell her about this interesting doc up in Cambridge named Don Berwick,) is more skeptical about the performance reporting elements of quality improvement. We asked her to guest post. Also if you identify with Garrett's comment about the "roller coaster" quality improvement ride, click back to this post on "The hype cycle," a term Joanne heard at an IHI conference).

Joanne Kenen’s recent post on the infection-charisma complex (great job on the title, by the way) led to a longer, off-line discussion between the two of us on whether optimism is warranted. I’ve been working in health care quality improvement since 1991 and I describe this work to my graduate students as an extended roller coaster ride: a rush of excitement--usually caused by a policy change, or a new commission, or a new IHI initiative--that a commitment to quality really will take hold and grow, followed by the stark reality described by Bob Wachter that, in fact, no, it won’t. I too doubt that the performance reporting initiatives you list are going to do the trick.

Why all the fear and loathing among physicians around alternative medicine? For those who’ve never been to this site, HCRenewal is ordinarily a terrific blog that features smart postings by physicians and health IT professionals. But there is one issue that makes them see red -- alternative medicine.

In a recent post, “New CMS Chief Donald Berwick: a Trojan Horse for Quackery?” Kimball Atwood frets that Don Berwick, who was recently appointed to head the Centers for Medicare and Medicaid Services, is such a strong supporter of patient choice that he may be too comfortable with patients' preferences for complementary and alternative medicine. In Dr. Atwood’s view, a February 2009 appearance by Dr. Berwick at Bravewell Collaborative-sponsored Summit on Integrative Medicine and the Health of the Public, where he shared the podium with Dr. Mehmet Oz, Dr. Dean Ornish, Senator Tom Harkin, was evidence that he was either naïve or had “gone over to the dark side." 

The “dark side?” Don Berwick?? C’mon.

Let’s talk about risk for a moment. Statistically, you are far more likely to experience a fatal accident in the car on the road than you are in an airplane. But somehow, hurtling through the sky thousands of feet in the air just feels more risky than being planted firmly on the ground. We perceive that we’re taking on more risk in an airplane than we are in a car, statistics be damned. According to a recent article in Health Affairs, a similar phenomenon happens to doctors when they think about malpractice. And it doesn't diminish all that much even when their states impose caps on malpractice damages.

We attended an event this morning, Medical Liability and Emergency Care, to mark the release of the September issue of Health Affairs. (Not that September Issue.) We got to listen to the minds behind the articles talk about some major issues in the health policy world -- medical malpractice reform, avoiding and managing medical errors, and problems surrounding emergency room use. Emily Carrier, Senior Health Researcher at the Center for Studying Health System Change, and one of the co-authors of the article about physician perception of malpractice risk, explained the article’s main conclusions.

Hospitals can be very hierarchical places, but patient safety and quality improvement is a top down, bottom up, everybody in this together task. The Agency for Healthcare Research and Quality (AHRQ)’s latest Innovations Exchange report spotlights how Chicago’s Northwestern Memorial Hospital. notably improved its patient safety culture. One key step was monthly meetings, including moderated panel discussions, where employees from all levels could hear or talk about adverse events that occurred, learn from them, and think through how to prevent mistakes from happening again.

The grants that President Obama authorized for new approaches to malpractice and patient safety -- including variants of the "disclose and apologize" model -- were awarded earlier this month. (See the full list here). One of the grantees was the University of Illinois team we wrote about both on the blog and for Miller-McCune magazine. Dr. Tim McDonald helped us understand some of the technical and legal barriers to moving toward an early disclosure system. It's a lot easier in an academic medical center where the doctors, nurses, hospital are all covered under the same malpractice policy, it's far more difficult in community settings where the doctors aren't hospital employees and a half dozen insurers with different economic interests and philosophies can be involved in a single case. We also came to understand it's not just the "apology" that matters, it is the commitment to identifying, analyzing and most importantly fixing problems that can lead to patient harm. The Illinois project attempts to go to the heart of this problem, taking the model from the university into community hospitals.

A couple of the grantees look at perinatal patient safety -- right before and after childbirth, a high risk for malpractice suits. One looks at malpractice in the outpatient setting.