All Entries in the "Patient safety" Category
The human side of patient safety
An article appearing in the New York Times earlier this week addresses an interesting view on the world on patient safety: with so much focus on preventing adverse events, treating patients as human beings has fallen by the wayside. The author contends that in an attempt to fill out the right forms, ensure the correct tests have been ordered, and make sure all regulations have been complied with to get patients back on their feet, healthcare workers are more interested in “satisfying the system” than treating patients.
I wonder if this idea is true and if so, is there anything that can be done to both provide care in a manner that is ‘by the book’ and take the time to get to know patients, and in doing so, help them heal? I think there is some truth to the opinion but I also think that patients are better off today (patient safety-wise) than they were ten or 15 years ago. Although patients may not know personally their physicians as well as they have in the past, they can be sure that measures are in place at their hospitals to help prevent them from acquiring certain infections, or encourage proper medication labeling.
What are your thoughts on the topic?
Another case of hospitals behaving badly
St. Francis Hospital and Medical Center in Hartford CT is the latest facility to make headlines for violating state regulations concerning patient care. The hospital was placed on probation by the Connecticut Department of Health, according to the Hartford Courant. One of the more recent instances involved a heart surgery patient who sustained a brain injury during a May18 surgery. The patient later died on June 18, and on July 2, the hospital stopped offering non emergent cardiac surgeries.
The major problem in this case stemmed from a pump failure with the pump used for cardiopulmonary bypass, according to the Courant. The hospital did not address the pump failure adequately. Specifically, the hospital didn’t report the pump failure to the Food and Drug Administration or the manufacturer or communicate the failure to hospital leaders and other members of the medical staff. Additionally some of those providers involved in the surgery did not participate in a cause analysis, and what I think constitutes the worst offense, the hospital put the pump that failed back into use just three or four days after the incident.
The hospital has issued a statement saying that it has made administrative changes, updated OR procedures, and revised equipment and maintenance protocols. You can find the full article here.
I wrote this post last week about a Rhode Island hospital that was fined by the state’s Department of Health. I know that these two cases are gaining media attention, so that’s not to say that other facilities in their area are not committing similar errors. But in reading the descriptions of how the situations were handled, it seems to me that neither facility really placed much emphasis on learning from their mistakes, which I think is what is most startling.
Joint Commission and HHS publish new video to improve patient-provider communication, reduce disparities in care
The Joint Commission and Health and Human Services released yesterday a 30-minute series of videos titled Improving Patient-Provider Communication: Joint Commission Standards and Federal Laws. The videos, which can be found on YouTube, were created out of recognition that there are a lack of resources out there that touch on methods for improving communication between patients and their providers for non English speaking patients, and patients who are hard of hearing. Additionally, the are many current regulations surrounding those topics, and The Joint Commission is developing a set of standards surrounding cultural competence, patient-centered care, and effective communication.
The project runs through January 2010. It will attempt to address how better to incorporate health literacy, culture, and diversity into Joint Commission standards. You can read more about the project here.
Diagnosis errors: No easy fix
Physicians are responsible forone of the most complicated and important decisions in medicine: the diagnosis. Any further treatment plan rides on this diagnosis, and it may not be surprising that diagnosis error is now being looked at as a significant percentage of all medical errors. A report published in the November 9 Archives of Internal Medicine showed that anonymously, 310 physicians revealed 583 diagnosis errors, of which 44% were related to lab and radiology testing errors, including test ordering, test performance, and clinician processing.
But why do physicians make diagnosis errors? The answer lies in both cognitive processes and they systemic factors that influence the way in which a medical decision is made.
I co-wrote an article for HealthLeaders Media today about diagnosis error. The idea came from listening to one of theInstitute for Healthcare Improvement’s recent WIHI programs on the topic, which, if you haven’t listened in to yet this year, are truly worth catching. There is a great dialogue between the expert speakers and the audience because they address many of the questions that listeners bring up while virtually “chatting” with one another. Anyway, the WIHI featured Gordon Schiff, MD, associate director at the Center for Patient Safety Research and Practice at Brigham and Women’s Hospital in Boston and Pat Croskerry, MD, PhD, professor in emergency medicine at Dalhousie University in Halifax, Nova Scotia. Both of these men are leaders in the field of diagnosis error and recently helped plan the second annual conference on the topic. Schiff is an author on the aforementioned Archives of Internal Medicine report.
Both men discussed that diagnosis errors occur more often than they are reported, and they have not been given as much attention to errors like medication errors, falls, and other tangible errors. This is because of the underreporting and also because it is harder to make the case that someone’s thinking was the cause of an error. In fact, diagnosis errors are partially the result of a cognitive impairment and partially the result of systemic failures—meaning the hospital system sets physicians up for failure.
I find the topic fascinating, what are your thoughts? The idea that people create certain thinking biases, often without even knowing it, and that that bias can factor into a decision that may determine the course of a patient’s treatment, even if it is the wrong treatment—it is a scary thought, but interesting nonetheless.
I suggest checking out the HealthLeaders article, please let me know of any feedback!
NCQA says quality of U.S. healthcare stagnant
After a decade of improvement, The National Committee for Quality Assurance has said that during last year the quality of healthcare was at a standstill in its annual State of Healthcare Quality Report. The study also found that there no links between higher spending and better healthcare outcomes. The quality data that the report is based off of was submitted by 979 health plans across the country that collectively cover 116 million Americans, which is a 9 percent increase over 2008. The health plans use the HEDIS measures, which stands for Healthcare Effectiveness Data and Information Set.
Some of the trouble spots from this year’s report include the following statistics:
- Only 46.4% of people taking anti-depressant drugs are monitored by their physicians;
- 34.1% of children prescribed medications for attention deficit hyperactivity disorder (ADHD) are seeing a doctor for follow-up care
- Half of patients previously hospitalized for mental illness see a physician for a follow-up visit
- 45.3% of people are receiving colon cancer screening at the appropriate age
- Only 42.6% of patients with alcohol or drug dependency are entering into treatment
There was also an increase in the overuse of medical imaging for back pain and breast cancer.
I think the most striking point to come out of the report is the NCQA’s estimation that if all health plans were able to perform at the level of the top 10 percent of plans, the U.S. would avoid up to 115,000 thousand deaths and save at least $12 billion in medical costs and lost productivity every year.
In light of this report, the NCQA asked Congress to include language about quality improvement in its final bill.
Does any of this surprise you? I was mostly shocked to hear that this was the first year that the report showed little change in quality improvement.
Mistake-proofing and its relation to process management
One of my colleagues at HealthLeaders Media, Cheryl Clark, wrote this columnyesterday about making things fail-proof–anything really. She starts out by giving the example of how her fancy refrigerator beeps when the doors have been open for too long, reminding owners to shut the doors. She used that analogy to draw some comparisons to many of the mistake-proofing devices in healthcare, and how we are now really are coming into the age of really predicting how an error might occur and designing systems better to prevent those errors.
I’ve been reading up a lot lately on process management and even when speaking with people in the healthcare industry, there seems to be a lot of momentum behind the Lean and Six Sigma, the notion of ridding our systems of waste if we truly want them to succeed–and be the easiest and most logical way of doing things. Designing processes so that they are “mistake-proof” certainly ties in.
I suggest reading her column, it’s a good one. Do you see a larger waste reduction and process improvement effort taking place at your facility?
Should physicians be required to take cultural competency courses?
It’s widely reported that racial and ethnic minorities receive less comprehensive healthcare than white patients. Some states have tried to address this by requiring physicians to undergo cultural competency training. Both California and New Jersey require such training and Maryland strongly recommends it. Nine other states are considering requiring some sort of cultural competency training.
However, an article in this week’s American Medical News points out that many physicians are opposed to such legislation mainly because it’s another topic around which they have to be educated. California and New Jersey have taken different approaches to mandating cultural competency training. California requires continuing medical education (CME) courses to contain information that is culturally and clinically relevant. New Jersey requires a specific amount of CME credits that must be earned in courses around cultural content as defined by the state medical board.
Some physicians opposed to the increased amount of cultural competence training wonder when the CME requirements will end and say that some requirements may not line up with what is clinically relevant. On the flip side, other physicians who are for such requirements say that without these mandates, most physicians would ignore the topic completely.
What does your state require? Do you think topic-specific CME mandates such as cultural competence are necessary for physicians? What about other healthcare workers?
Another reason to celebrate October: Next week is International Infection Prevention Week
The worldwide healthcare community will be observing International Infection Prevention Week (IIPW) next week, from October 18-24. The Association for Professionals in Infection Control and Epidemiology (APIC), which spearheads the effort in the U.S., is urging all states and Congress to recognize the week as a way of bringing attention to the work that infection preventionists do and the toll that infections take on patients in many healthcare settings.
The theme for IIPW 2009 is “Infection Prevention is Everyone’s Business.” In conjunction with this theme, APIC will be offering a couple of Webinars with special theme days during that week:
- Tuesday, October 20: Collaboration
- Wednesday, October 21: Hand hygiene
- Thursday, October 22: Surgical site infections/ operating room safety
Additionally, the group will announce the winner of the first annual Healthcare Administrator Award, which will be given to a healthcare executive who has demonstrated continuing support for infection prevention at his or her facility. The announcement, which kicks off the observance of IIPW, will take place at a ceremony on Friday, October 16, during a live Webcast at 1 pm Eastern time. Specific APIC chapters located in New York City, Dallas/Fort Worth, TX, and St. Paul/Minneapolis, MN, will be hosting their own satellite events in conjunction with Friday’s announcement.
Is your hospital doing anything to honor IIPW?
October celebrates Health Literacy Month, National Healthcare Quality Week
The month of October brings us two health-related events to celebrate: Health Literacy Month and National Healthcare Quality Week (October 18-24). Both events give healthcare workers and their organizations a chance to think about current practices and how to improve in the name of patient safety.
Health Literacy Month, which was started by Helen Osborne, MEd, OTR/L, a health literacy consultant, in 1999. This year’s theme is “Why Health Literacy Matters: Sharing Our Stories in Words, Pictures, and Sound” and is accompanied by an informative Web site (www.healthliteracymonth.org). Each day during the month of October a new health literacy “story” is added to the “stories section of the Web site. One of these highlights a couple of songs sung by Mache Seibel, MD, in honor of the month. You can find more of his songs at the Web site www.healthrock.com. Additionally, the Health Literacy site provides different resources and materials for the month.
National Healthcare Quality Week (NHQW) is being observed next week and the National Association for Healthcare Quality’s (NAHQ) Web sitecontains news about continuing education opportunities and events in honor of the week. The time is meant to highlight those healthcare workers whose quality work influences patient outcomes for the better. It also provides suggestions for ways that healthcare facilities can promote and publicize NHQW or any NHQW-related events being put on in the organization or larger community.
Are any of your facilities observing Health Literacy Month or National Healthcare Quality Week? What has your hospital done?
The sleep factor: Do less tired physicians deliver safer care?
The debate on whether reducing the number of hours that graduate medical students can work consecutively, as well as per week, has had any effect on the safety of patient care continues, reports American Medical News. Last year the Institute of Medicine made even further recommendations for reducing the number of hours that residents can work, based on sleep science. Those suggestions have yet to be implemented. However, there is evidence both for and against further reducing the amount of hours that residents can work.
Since 2003, residents are allowed to work no more than 80 hours each work week. However, each time residents’ shifts are over, they must hand their patients off to new residents. More handoffs often lead to an increase in poor patient safety outcomes. However, tired residents also may not able to make appropriate decisions regarding patient care. Sleep deprivation affects each person differently. Additionally, it’s difficult to truly measure patient safety and what may affect it.
To read more from American Medical News, click here. Has your facility had any open discussions regarding resident hours?
