September 23rd, 2012 by Dr. Val Jones in Health Policy, Opinion
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In another example of government over-reach, the NYT describes how the Obama administration is enlisting the help of patients to report physicians (whom they believe may have made a medical error), directly to the federal government. While there are systems already in place for such reports at the local hospital level, apparently the “under reporting of medical errors” has triggered AHRQ to pilot a program in which questionnaires are sent to patients to ferret out potential examples of errors caused by the following:
* “A doctor, nurse or other health care provider did not communicate well with the patient or the patient’s family.”
* “A health care provider didn’t respect the patient’s race, language or culture.”
* “A health care provider didn’t seem to care about the patient.”
* “A health care provider was too busy.”
* “A health care provider didn’t spend enough time with the patient.”
* “Health care providers failed to work together.”
* “Health care providers were not aware of care received someplace else.”
So if a patient determines, for example, that a physician did not spend enough time with them, and they believe that resulted in a medical error (whatever that might be), they can/should report the physician to the federal government. Wow. One physician explains the potential hazards of such a process:
Dr. Kevin J. Bozic, the chairman of the Council on Research and Quality at the American Academy of Orthopaedic Surgeons, said it was important to match the patients’ reports with information in medical records.
“Patients’ perceptions and experience of care are very important in assessing the overall success of medical treatments,” Dr. Bozic said. “However, patients may mischaracterize an outcome as an adverse event or complication because they lack specific medical knowledge.
“For instance, a patient may say, ‘I had an infection after surgery’ because the wound was red. But most red wounds are not infected. Or a patient says, ‘My hip dislocated’ because it made a popping sound. But that’s a normal sensation after hip replacement surgery.”
I believe that reporting medical errors is critical in the process of quality improvement, but that is most efficiently handled at the hospital level. There is no need to involve the federal government at the earliest stages of investigation, and the amount of bureaucracy required to support such an effort boggles the mind.
In the past when I encountered medical errors in the hospital setting, I found successful ways to report the incidents to the local administration. The result was a rapid correction of the problems and new processes put in place to ensure that it didn’t happen again. This is how medical errors should be reported and resolved. Soliciting patients for accounts of subtle lapses in social graces by their healthcare providers, and then reporting them to the government for it, is nothing short of Big-Brother creepy.
August 15th, 2012 by Dr. Val Jones in Health Policy, Opinion
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Hospitals can be dangerous and inefficient; therefore it is easy to connect with Atul Gawande’s recent New Yorker essay “BigMed” suggesting that the streamlined, production processes found at the Cheesecake Factory can and likely will be applied to healthcare. Yet hospital care should not be confused with the full spectrum of healthcare. One must make the distinction between the cognitive process of medical diagnosis occurring in exam rooms, with the procedural basis of surgical care and hospital recovery. While Dr. Gawande has provided a wonderful revealing portrait of cost-effective, fast, food preparation and delivery at the Cheesecake Factory, he has focused on the process of creating the meal, not the process of deciding what meal to make. Successful surgery, for the wrong diagnosis, is a problem. If we are to solve some of healthcare’s largest failings we should focus on what happens as physicians try to address their patient’s problems, diagnose and make decisions, at the table of medicine called the exam room.
Consider the continuum of the patient encounter, from first symptoms, through diagnosis and therapy at a restaurant called Med. At Med I spend all of my shifts with my patrons at my tables. This is an unusual restaurant since the patrons are never sure of what they want to eat and appear every 20 minutes with ever changing lists of unique groups of ingredients to share with me. There are varying ingredients and thousands of meals that can be created. The patrons know the ingredients, but not the meal that they would like to eat. From memory I respond to the customers list of ingredients and ask many questions, take the pulse and other vital signs of the customer, order blood samples, radiographic studies and then decide for the patron which meal their ingredients add up to. All from memory. At Med, restaurant patrons also ask for foods and “food tests” they have seen on television all purported to be risk free. Further complicating the process is my customer is not out for a fun and relaxing evening, they are in small booths in skimpy, open at the back gowns, often anxious and uncertain if they will be harmed or poisoned by my foods, or simply receive a meal they do not want. Some are in pain and some are depressed, while other customers are totally unrealistic about the meal that is to be delivered. You see at Restaurant Med, where patrons only can speak to their wait staff about ingredients, and demand the modern but unhelpful ovens they heard about from friends and the media, it is really difficult to create meals that patrons thoroughly enjoy.
An appendectomy should be consistently performed and priced, but how do we consistently perform and price considering the ambiguity inherent in diagnosis itself? Unlike a restaurant, where customers choose a meal by ordering a meal, at restaurant Med some higher force gives an unfortunate person an undifferentiated and undiagnosed problem that needs and deserves an answer. As it turns out, none of the patrons really want to be eating at restaurant Med, as they always receive a meal they did not ask for.
Patients do not choose their diagnoses from menus; doctors must discover and diagnose them.
If your waiter tries to memorize all the orders at all the tables, you might get the wrong meal, and if your server is in a hurry, thai dipping sauce might be spilled on your new silk blouse. Likewise if physicians are in a rush, they might not take a thorough history, perform a complete physical exam, or have an accurate and thorough list of diagnostic possibilities, ultimately resulting in the wrong diagnosis. If your physician believes he or she can memorize all the questions, tied to all the possible diagnoses you also might receive the wrong diagnosis. With that wrong diagnosis you might end up in a hospital more efficient than the Cheesecake Factory with doctors efficiently ordering unnecessary tests, and performing wrong surgeries for the wrong diagnosis all with the ease and speed of the best assembly line on the planet.
Diagnostic and patient management error caused by cognitive mistakes in the exam room are all too often overlooked and unmentioned in the discussion of repairing our broken healthcare system. There are over a billion outpatient visits in the US each year, and numerous studies have shown 15-20% of these visits have an inaccurate diagnosis. Autopsy data proves this, malpractice insurers know this, and policy makers avoid it. Add diagnostic error in the emergency room and walk-in clinics to error in the out-patient offices of medicine and you have more than 200 million errors. If we are to resolve some of healthcare’s deepest woes we need to address diagnostic errors and the decision-making occurring at the restaurant table of medicine, the exam room. A bright light needs to be shined on the simple fact that there is too much to know, to ask and to apply during a 15 minute encounter unless the patient has the simplest of medical questions or problems. Medical informaticists, researchers and innovative companies are focusing on this essential limitation of medical decision-making by designing information systems to be used by physicians at the point of care, during the patient encounter. Problem oriented systems can also be designed for use by patients in advance of the visit, and the future holds home-based information coordinated with professional clinical decision support. These new information tools are beginning to take the guessing out of which ingredients (symptoms) relate to the meals that the patient ultimately receives (diagnosis and treatment). If medical care is truly to be driven back to primary care we need to arm the waiters of medicine with purposefully designed tools and training to resolve ambiguity, aid diagnosis and inform therapy in the exam room.
Art Papier MD
Art Papier MD is CEO of Logical Images the developer of www.visualdx.com a clinical decision support system, Associate Professor of Dermatology and Medical Informatics at the University of Rochester College of Medicine, and a Director of the Society To Improve Diagnosis In Medicine (SIDM) http://www.improvediagnosis.org/
January 1st, 2012 by Medgadget in News
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The airline industry has long been a paradigm example of safety, but it was not always that way. The transition occurred over the second half of the 20th century and was marked by rigorous equipment testing and procedures, such as the strict incorporation of checklists. Healthcare is an industry that recently has become quite interested in the possibility of implementing airline industry standards to improve patient safety and care delivery (read the books The Checklist Manifesto and Why Hospitals Should Fly if you’d like a solid overview of this phenomenon)
This month Lockheed Martin and Johns Hopkins, two institutional leaders in the fields of aviation and healthcare, respectively, announced a partnership to bring cutting-edge systems integration to the intensive care unit (ICU). According to the press release: Read more »
*This blog post was originally published at Medgadget*
November 22nd, 2011 by RyanDuBosar in Research
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Alarm fatigue is the most dangerous of health care technology hazards, topping even radiation exposure and medication errors from infusion pumps, according to the updated Top 10 list offered by ECRI Institute.
It’s not surprising that alarm fatigue rang in at #1. There can be as many as 40 alarms an hour in some units. Staff modify alarm setting outside of safe parameters, can’t tell the alarm’s importance (or even which device is issuing it) or the alarm isn’t relayed to the paging system, according to ECRI Institute, a nonprofit organization focusing on patient-safety and cost-effectiveness in health care. Its report (registration required) is online. The report includes recommendations and resources for each of the 10 top hazards.
Staff may turn alarms off or down to reduce alarm fatigue, as well as reduce stress on the patient and family, the report notes. And properly setting alarms is complex to begin with, so ECRI offers best practices to reduce alarm fatigue while maintaining patient safety: Read more »
*This blog post was originally published at ACP Hospitalist*
November 20th, 2011 by RyanDuBosar in Research
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Adults who received care from a medical home in 11 Westernized countries were less likely to report medical errors and were happier with their care, according to a new Commonwealth Fund international survey.
The 2011 survey included more than 18,000 ill adults in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States. It included people who reported they were in fair or poor health, had surgery or had been hospitalized in the past two years, or had received care for a serious or chronic illness, injury or disability in the past year. The vast majority had seen multiple physicians.
A medical home was defined as patients reporting a regular source of care that knows their medical history, is accessible and helps coordinate care received from other providers. Results were published in Health Affairs.
Sicker adults in the U.S. were the most likely to Read more »
*This blog post was originally published at ACP Internist*
