Thursday, February 26, 2009

Public reporting

From the Midwest comes this opinion about the value of public reporting of medical errors. As I have said elsewhere, if the medical profession does not establish its own standards in this arena, government will do so for us.

6 comments:

Shelly Gordon said...

Since the Institute of Medicine report referred to in SLT Today.com is from 1999 do you think this reflects current statistics. I would assume progress has been made and prevention practices put in place to reduce the number of deaths related to medical errors.

Anonymous said...

Paul - Intersting quote from the article : "Virtually every American hospital has a system to collect adverse-event reports. But just one in five distributes summaries so that doctors and nurses can prevent adverse events." This is so true and often overlooked. At BID we collect volumes of information but it is impossible for most front line clinicians to use the data bases. They are not easy to manipulate and there is mimimal (or no) adminstrative support to help run queries etc. It seems in the absence of good data what often ends up in the newspaper as 'quality data or transparency' are actually random events. Using the small amount of data we have then in turn creates a culture of fear. But if we could prioritize improving our data systems at BID then we could then begin to really address some of the quality issues - that are clearly frustrating.

Paul Levy said...

Dear Anon,

Thanks, but what you are writing about is abit unclear. Could you please contact Ken Sands and explain in more detail?

Dear Needham volunteer,

I received your post and have forwarded it to the right people.

Anonymous said...

I think Anon has something---- Transparency in and of itself is not quality. My experience at BID is that there is a great deal of talk and self praise about change -but its just talk with no real understanding as to the resources and culture needed to really make a difference.

Paul: Get the physicians involved in the plan and stop playing the blame game - and you'll have a winner.

Paul Levy said...

Dear Anon,

It is hard to imagine a hospital that is less involved in a "blame game" than ours. Indeed, we have done so much to avoid blame and punishment.

Also, we have -- collectively -- already made tremendous differences in quality and safety. The numbers about reduction of central line infections, VAP, and mortality (because of the Triggers program) are real and documented. Physicians designed and carried out these program, in cooperation with the nurses and others.

I would like to hear from you in person about these issues. You know how to contact me, or your division chief, or your department head if you have suggestions.

Anonymous said...

Paul - Thanks for the offer - but I left BID at the end of residency. I should have had an exit interview with you... oh well sounds like things are maybe changing. Just remember physicians are human and unfortunately do make mistakes. Good Luck- I wish you and BID the best.