March 4th, 2010 by GruntDoc in Better Health Network, Opinion
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The American Board of Emergency Medicine (ABEM) describes itself as:
Welcome to the American Board of Emergency Medicine (ABEM) public website. ABEM certifies qualifying physicians who specialize in Emergency Medicine and is a member board of the American Board of Medical Specialties (ABMS). ABMS certification is sought and earned by physicians on a voluntary basis. ABEM and other ABMS member boards certify only those physicians who meet high educational, professional standing, and examination standards. ABEM and other ABMS member boards are not membership associations.
The thing I’d like to bring your attention to is that it’s a Voluntary organization. For a voluntary organization they’re adding lots of requirements without asking members… Read more »
*This blog post was originally published at GruntDoc*
October 15th, 2009 by Happy Hospitalist in Better Health Network, Opinion
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Over at the WSJ Health Blog, some academic docs, such as hospitalist Dr. Wachter are suggesting just that.
Punishments such as revoking privileges for a chunk of time tend to be used for administrative infractions that cost the hospital money – things like failing to sign the discharge summaries that insurance companies require to pay the hospital bill. By contrast, hospital administrators may just shrug their shoulders when it comes to doctors who fail or refuse to follow rules like a “time out” before surgery to avoid operating on the wrong body part.
Docs and nurses who fail to follow rules about hand hygiene or patient handoffs should lose their privileges for a week, Pronovost and Wachter suggest. They recommend loss of privileges for two weeks for surgeons who who fail to perform a “time-out” before surgery or don’t mark the surgical site to prevent wrong-site surgery.
This couldn’t have come at a better time. At Happy’s hospital there is a massive witch hunt to crack down on not signing off verbal orders within 48 hours. This has nothing to do with patient safety. It has everything to do with meeting the requirements of CMS so the hospital does not lose their funding. Read more »
*This blog post was originally published at A Happy Hospitalist*
September 25th, 2009 by Happy Hospitalist in Better Health Network, Humor, Opinion
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Over the last several weeks I have received numerous emails dictating the enforcement of work place rules regarding eating and drinking in nursing areas and other areas with patient charts. It seems everyone, from the Chief of Staff to the CEO to the Head Nurse In Charge has been making it very clear that drinking in work areas won’t be tolerated. I have at times been confronted by dutiful staff doing their jobs with a robust sense of confidence to enforce this potentially dangerous patient safety issue.
Or so I thought. Whilst speaking with one of Happy’s friendly colleagues, I learned that the issue of food and drink in the work place has nothing to do with patient safety. Like my colleague stated so eloquently, if there is data that can be presented to me that shows my action of drinking coffee at the work stations would some how harm my patient, I will gladly stop immediately. Discussion finished.
But as I learned from my colleague, the issue of food and drink at the nurse’s station or anywhere near patient charts has nothing to do with patient safety. In fact, the regulations are in place to protect ME from myself.
That’s right, the coffee Nazis are cruising the halls with reckless abandonment searching for violators of the hospital wide coffee ban on rounds not because patients could be harmed, but because I could harm myself.
You see, it turns out my distinguished colleague was told these regulations were not CMS or JCAHO regulations, but rather OSHA regulations.
So I looked it up
“OSHA does not have a general prohibition against the consumption of beverages at hospital nursing stations. However, OSHA’s bloodborne pathogens standard prohibits the consumption of food and drink in areas in which work involving exposure or potential exposure to blood or other potentially infectious material takes place, or where the potential for contamination of work surfaces exists 29 CFR 1910.1030(d)(2)(ix). Also, under 29 CFR 1910.141(g)(2), employees shall not be allowed to consume food or beverages in any area exposed to a toxic material. While you state that beverages at the nursing station might have a lid or cover, the container may also become contaminated, resulting in unsuspected contamination of the hands.
Here are the actual OSHA regulations
1910.1030(d)(2)(ix)
Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is a reasonable likelihood of occupational exposure.
1910.141(g)(2)
Eating and drinking areas. No employee shall be allowed to consume food or beverages in a toilet room nor in any area exposed to a toxic material.
In other words this is not a patient safety issue, but rather an employee safety issue. The Joint Commission has no specific standard on the issue other than for hospitals to comply with OSHA regulations.
So with that in mind, I have two comments regarding the issue:
- As a private practice physician who is not employed by the hospital, I would suggest that these OSHA rules do not apply to me and therefore the hospital risks no retribution for noncompliance from the accreditation arm of the Joint Commission, which is why I suspect the issue comes center stage for hospitals everywhere. If necessary, I will gladly sign a waiver to relinquish my rights to compensation should I ever contract a blood born pathogen or other communicable disease from drinking my coffee.
- If the hospital believes this is a patient safety issue and wishes to make their regulations stronger than those of OSHA and apply them to ALL people in areas with patient pathogens, I will gladly relinquish my daily fluids when I am shown the data regarding patient harm AND the hospital also bans all patient guests from bringing food or drink into the patient’s room. If this is a patient safety issue, it must apply to everyone should they wish to make their rules stronger than OSHA guidelines.
Until this is resolved with rational thought, perhaps over a round of coffee, I’m going to carry one of these around:
It always seems to work for patients.
*This blog post was originally published at A Happy Hospitalist*
August 11th, 2009 by DrPaulSAuerbach in Better Health Network, Health Tips
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One of the most dangerous times for a patient is during the transition, or “handoff,” between providers. This is due to a number of reasons. First, the original provider(s) may not relay all the information he or she knows about the patient to the next provider(s). Second, the accepting team may take it for granted that everything is known about the patient, and therefore not take a complete history or perform an adequate physical examination. Third, if the patient initially looks good, the accepting providers may be lulled into a false sense of security, and not anticipate a deterioration in the patient’s condition.
We know this problem to exist in the hospital setting. Survey of doctors-in-training suggests that handoffs may commonly lead to patient harm. Last year (2008) in September, there was a blog written by Elizabeth Cooney in the Boston Globe that stated, “a 2006 survey of resident physicians at Massachusetts General Hospital found that handoffs commonly lead to patient harm, according to an article in The Joint Commission Journal on Quality and Patient Safety.” More than 50 percent “of the 161 medical or surgical residents who responded to the anonymous survey said they recalled at least one occasion in their last month-long rotation when a patient suffered from flawed handoffs.” Approximately “one in nine said the harm that resulted was significant.” The respondents said that “if the patient was coming from the emergency department or from another hospital, problematic handoffs were more likely.”
This holds true in the field. Unless the new treatment team makes the assumption that they need to begin their assessment of the patient’s condition from scratch, they are more likely to make a mistake. Obviously, such caution depends on the possible severity of the patient’s condition and the rescue/environmental situation. If I can get a decent handle on a patient’s condition, and there is little or no risk of me missing something, I will tailor my questioning and examination to suit the circumstances. However, I always start from the position that something has been hidden from me, of course not intentionally, and that the patient’s initial assessment has underestimated the problem(s).
I cannot begin to tell you how many times I have found something that was missed, or have accepted the care of a patient just as he or she began to “crash.” This is in no way a criticism of others, just a common fact of medical care. Previous rescuers may have been tired, the conditions may not have been conducive to a full examination, the patient may have been withholding information, or the situation may have just taken its natural course and worsened. Regardless, it’s my responsibility to learn what I can as quickly as I can about my patient, so that nothing slips through the cracks.
Here are some simple rules to follow:
1. If the situation permits, ask your new patient to repeat his or her history. If they are reticent to engage in a long conversation, at least try to get them to relate current relevant events.
2. Repeat as much of the physical examination as you can. Explain to the patient that you have assumed their care, and that in order to do the best that you can on their behalf, it’s important for you to understand their issues and to be able to monitor their progress based up the exam.
3. Assume that until you have talked to the patient or otherwise obtained a comprehensive history, and performed a physical examination with your own hands, eyes, and ears, that you do not know as much about your patient as you could.
4. If a patient is under your care for a prolonged time, or if you are managing a situation prone to rapid or undetected deterioration, interview and examine your patient as often as is necessary and practical. If you must be absent from a patient for a longer period than is prudent between examinations, delegate the responsibility to someone else.
image of leg splinting courtesy of www.princeton.edu
This post, Dropping The Ball In Patient Care: Provider Handoffs, was originally published on
Healthine.com by Paul S Auerbach M.D., M.S..
November 8th, 2008 by drval in Celebrity Interviews, Expert Interviews
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Dr. Gawande
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Kaiser Permanente sponsored a special event in DC today - Charlie Rose interviewed Dr. Atul Gawande about patient safety in front of an audience of physicians. Dr. Gawande is a young surgeon at Harvard’s Dana Farber Cancer Institute, has written two books about performance improvement, and is a regular contributor to the New Yorker magazine. I had heard many positive things about Atul, but had never met him in person. I was pleasantly impressed.
Atul strikes me as a genuinely humble person. He shifted uncomfortably in his chair as Charlie Rose cited a long list of his impressive accomplishments, including writing for the New Yorker. Atul responded:
I’m not sure how my writing became so popular. I took one fiction-writing class in college because I liked a girl who was taking the class. I got a “C” in the class but married the girl.
He went on to explain that because his son was born with a heart defect (absent aortic arch) he knew what it felt like to be on the patient side of the surgical conversation. He told the audience that at times he felt uncomfortable knowing which surgeons would be operating on his son, because he had trained with them as a resident, and remembered their peer antics.
Atul explained that patient safety is becoming a more and more complicated proposition as science continues to uncover additional treatment options.
If you had a heart attack in the 1950’s, you’d be given some morphine and put on bed rest. If you survived 6 weeks it was a miracle. Today not only do we have 10 different ways to prevent heart attacks, but we have many different treatment options, including stents, clot busters, heart surgery, and medical management. The degree of challenge in applying the ultimate best treatment option for any particular patient is becoming difficult. This puts us at risk for “failures” that didn’t exist in the past.
In an environment of increasing healthcare complexity, how do physicians make sure that care is as safe as possible? Atul suggests that we need to go back to basics. Simple checklists have demonstrated incredible value in reducing central line infections and surgical error rates. He cited a checklist initiative started by Dr. Peter Pronovost that resulted in reduction of central line infections of 33%. This did not require investment in advanced antibacterial technology, and it cost almost nothing to implement.
Atul argued that death rates from roadside bombs decreased from 25% (in the Gulf War) to 10% (in the Iraq war) primarily because of the implementation of check lists. Military personnel were not regularly wearing their Kevlar vests until it was mandated and enforced. This one change in process has saved countless lives, with little increase in cost and no new technology.
I asked Atul if he believed that (beyond check lists) pay for performance (P4P) measures would be useful in improving quality of care. He responded that he had not been terribly impressed with the improvements in outcomes from P4P initiatives in the area of congestive heart failure. He said that because there are over 13,000 different diseases and conditions, it would be incredibly difficult to apply P4P to each of those. He said that most providers would find a way to meet the targets - and that overall P4P just lowers the bar for care.
Non-punitive measures such as check lists and applying what we already know will go a lot farther than P4P in improving patient safety and quality of care.
Atul also touted the importance of transparency in improving patient safety and quality (I could imagine my friend Paul Levy cheering in the background). In the most touching moment of the interview, Atul reflected:
As a surgeon I have a 3% error rate. In other words, every year my work harms about 10-12 patients more than it helps. In about half of those cases I know that I could have done something differently. I remember the names of every patient I killed or permanently disabled. It drives me to try harder to reduce errors and strive for perfection.
Atul argued that hospitals’ resistance to transparency is not primarily driven by a fear of lawsuits, but by a fear of the implications of transparency. If errors are found and publicized, then that means you have to change processes to make sure they don’t happen again. Therein lies the real challenge: knowing what to do and how to act on safety violations is not always easy.
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Charlie Rose
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Charlie Rose asked Atul the million dollar question at the end of the interview, “How do we fix healthcare?” His response was well-reasoned:
First we must accept that any attempt to fix healthcare will fail. That’s why I believe that we should try implementing Obama’s plan in a narrow segment of the population, say for children under 18, or for laid off autoworkers, or for veterans returning from Iraq. We must apply universal coverage to this subgroup and then watch how it fails. We can then learn from the mistakes and improve the system before applying it to America as a whole. There is no perfect, 2000 page healthcare solution for America. I learned that when I was working with Hillary Clinton in 1992. Instead of trying to fix our system all at once, we should start small and start now. That’s the best way to learn from our mistakes.
