Friday, November 26, 2010

Painfully slow

You can already imagine the responses. "That's just in North Carolina." "Our patients are sicker." "There are problems with the data."

What would prompt that? This New York Times article, citing a forthcoming NEJM study about medical errors in North Carolina. Here's the lede:

Efforts to make hospitals safer for patients are falling short, researchers report in the first large study in a decade to analyze harm from medical care and to track it over time.

The study, conducted from 2002 to 2007 in 10 North Carolina hospitals, found that harm to patients was common and that the number of incidents did not decrease over time. The most common problems were complications from procedures or drugs and hospital-acquired infections.

Other excerpts:

Dr. Landrigan’s team focused on North Carolina because its hospitals, compared with those in most states, have been more involved in programs to improve patient safety.

But instead of improvements, the researchers found a high rate of problems.

. . . The findings were a disappointment but not a surprise, Dr. Landrigan said. Many of the problems were caused by the hospitals’ failure to use measures that had been proved to avert mistakes and to prevent infections from devices like urinary catheters, ventilators and lines inserted into veins and arteries.

And another:

Dr. [Bob] Wachter said the study made clear the difficulty in improving patients’ safety.

“Process changes, like a new computer system or the use of a checklist, may help a bit,” he said, “but if they are not embedded in a system in which the providers are engaged in safety efforts, educated about how to identify safety hazards and fix them, and have a culture of strong communication and teamwork, progress may be painfully slow.”

Exactly right, Bob! What does it take to motivate this profession? What does it take to make process improvement part of medical school and residency training programs.

Painfully slow, and painful or worse to patients.

Addendum: Dr. Wachter also discusses this study on his blog, here.


Jeffrey N. Catalano said...

The study also reported that about 18 percent of patients were harmed by medical care, some more than once, and 63.1 percent of the injuries were judged to be preventable. Most of the problems were temporary and treatable, but some were serious, and a few — 2.4 percent — caused or contributed to a patient’s death, the study found.

A 1 in 5 chance of being harmed in a hospital by a medical error is terrifying and unacceptable, since all of us and our families have been, or will be, patients in the medical system at some point in our lives. It forces all of us to be on our toes the entire time we are in the hospital. Because the longer we are there, the greater the chance that one of the numerous random health care providers involved in our care is going to make a mistake with our medication, fail to pick up on a life-threatening condition such as an infection, or simply allow orders and tests to fall through the cracks.

So, until someone comes up with a good plan to improve healthcare, we need to be our own best advocates. For a terrific patient tool that will prevent miscommunication and medical errors go to This was developed by patient safety advocate Sorrel King, who lost her young daughter through a medical mistake and has been at the forefront of preventing this from happening to others.

Anonymous said...

So much for physicians policing themselves: it is a great system for those it protects from accountability. The less skilled among them can easily evade detection from management (with the help of collegial tolerance), hierarchies reinforce special status, and as long as providers don't make huge mistakes (e.g. 'never events'), they can go about their business until retirement.

Few organizations have managed to shift the cost of doing harm to the provider, or incentivized quality improvement enough to compel change in behavior. Sadly, I am coming to believe that patient harm is taken as a cost of doing business, collateral damage, if you will. Only when governance, management, and the public have predictable access to variation in physician performance will this change. All, I think, are too bamboozled to demand it.

76 Degrees in San Diego said...

In answer to your two posed questions, this is the direction of professional organizations. An example is the American Board of Family Medicine Maintenance of Certification program...

Anonymous said...

Anon 1:56;

I'm afraid I share much of your cycnicism, but it's even worse than just "access to variation in physician performance". It is known, for instance, that physicians have the worst statistics in adherence to certain safety policies like handwashing, yet variance from these policies is not currently measured, much less penalized, on the part of the individual physician. Instead, hands are wrung collectively at monthly meetings and then everyone goes back to what they were doing.
My uncomfortable conclusion is that it will take loud and embarrassing pressure from watchful patients/families, perhaps with the addition of the much-despised legal system, to get physicians' and hospitals' attention (present company excepted, Paul.)

nonlocal MD

Anonymous said...

Anon 2:39 PM: Exposure is usually as you say: continued pleas to do things differently, or front-page harm that sends feathers flying, temporarily.

Now with the use of video cellphone cameras, patients and families can record the behavior of providers. It could be like a 'candid-camera' expose on u-tube (after discharge, of course). Or some sampling observations, with frequency of behaviors (e.g. hand-washing) recorded. Secret shoppers have changed office behaviors, can they change care behaviors? It doesn't do much for trust in the system, but neither does the actual data.

Jeffrey N. Catalano said...

Improvements in safety features of automobiles over the past years has resulted in a death toll in 2009 that is the lowest in 50 years, according to a recent federal Dept. of Transportation report. Much of this has resulted from the ability of consumers to compare safety ratings published by the insurance industry. In addition, car makers must notify consumers when there is a safety defect and have 5 business days to notify the safety agency. (When Toyota failed to immediately report the problem with “sticky” gas pedals, it paid a record fine.) What’s really impressive is that the car makers have been able to pack their cars with more safety features without significantly increasing the cost of the car.
In healthcare, however, discussions about medical errors, how they occurred, and whether they were due to faulty systems, are protected by peer review statutes. All of that is highly confidential and takes place without patients ever being notified that there was such as meeting. In fact, patients are completely prohibited by statute from accessing the information. The reasoning for this is to encourage physicians to report and speak openly about medical mistakes without fear of being sued so that safety measures can take take place. The NEJM article confirms that peer review protections (which North Carolina also has) simply do not improve health care quality.
Without transparency, disclosure, and accountability, our healthcare system will never improve. Yes, it is embarrassing to disclose mistakes, for everyone in every industry. However, we need to rise about individual egos and concerns over personal liability and recognize the overriding common good of safe healthcare.
Otherwise, we will continue to lose 100,000 Americans each year from medical mistakes. That number was once three times the number of people who die from auto accidents. Now, it appears, that gap is widening.

70-293 said...

we will continue to lose 100,000 Americans each year from medical mistakes. That number was once three times the number of people who die from auto accidents. Now, it appears, that gap is widening.