Thursday, July 21, 2011

When will UPMC explain the whole story?

The UPMC kidney transplant story continues to develop.  This was the one where a doctor and nurse were disciplined in a matter that clearly reflected some systemic problems, more than personnel problems regarding those two people.

Now UPI reports: 

A report by a federal agency on a kidney transplant at the University of Pittsburgh Medical Center suggests more problems than the hospital has acknowledged.

The Centers for Medicare and Medicaid Services said its investigation found the nephrologist should have been aware the kidney donor was infected with hepatitis C, the Pittsburgh Post-Gazette reported Tuesday. The hospital has suspended the lead surgeon and the transplant coordinator.

The CMS report said the test results were available for two months in the donor's medical record. But none of the doctors and nurses apparently reviewed the record, and the kidney was transplanted into a man who was not infected with the virus.

The story concludes in a manner that feels like an oxymoron with regard to confidence: 

Dr. Abhinav Humar, the head of the UPMC transplant coordinator, said he is confident the hospital has developed appropriate corrections for its failures.

Wouldn't it be great if UPMC would tell the whole story and help all the transplant centers in the world understand the nature of the problems that occurred, so all could benefit from this experience and improve programs worldwide?


Anonymous said...

Interesting that the safety literature has moved on from the idea of the physician as the 'captain of the ship' who has sole and ultimate authority and responsibility - but inspecting agencies continue to hold the physician solely responsible for problems. This is deliberate - it happened in my shop also, where the medical director was held responsible in a CLIA inspection for systemic and longstanding problems that reflected more on the administration.
"Teamwork" sounds all well and good till the hammer comes down - then it comes down on the doctor. Perhaps this is why UPMC is silent; it escapes accountability that way.
Time for CMS and the states to get with the latest picture, otherwise only lip service will be paid to the 'teamwork' idea by physicians.

nonlocal MD

Anonymous said...

Sorry; I did not read the actual story before the first comment - a nephrologist is not a surgeon. So it sounds like CMS held one doctor responsible and UPMC demoted another doctor instead - assuming the story is accurate. Just demonstrates the futility (stupidity, really) of trying to decide on which single person to pin blame......


Dr. Mary said...

Wow. My PGY-2 residency was spent specializing in transplant medicine. This brings back memories.
We are human, undesireable events will take place; I agree it is most important to learn from these events and to help prevent them from recurring.

Barry Carol said...

Paul –

Of course it would be great if UPMC told the whole story to help transplant programs worldwide improve. While I don’t actually know why they don’t, I suspect the answer is that UPMC doesn’t see anything in it for THEM if they do so. The idea that it would be the right thing to do apparently doesn’t count for much with well known market dominant health systems like UPMC that are mainly interested in sustaining and enhancing their competitive position in the market. Widely publicizing mistakes, along with corrective actions taken to prevent a recurrence, probably isn’t considered helpful in that regard.

Anonymous said...

This case is particularly troublesome because all transplant programs have very detailed pathways (or should have) for evaluating and checking on the donor evaluation test. There is a nurse coordinator who should be checking, the nephrologist, AND the surgeon. Like most medical errors it is usually a series of mistakes. Pittsburgh has always been big on numbers, not so much on process.

Paul Levy said...

Exactly, Barry, and exactly the kind of mindset that keeps medicine from being as safe and effective as it could be. Imagine the kudos they would get, worldwide, if they took the initiative -- especially as an academic medical center -- for providing a full evaluation of what went wrong. I would see no diminution in their prestige: Quite the contrary.

Anonymous said...

I heard a hospital physician complain that he has lost patients to other hospitals because of the reputation damage caused by his institutions' public (in this case, front page) reporting of harm events. This is a shame. Not only because humans are pretty bad at calculating risk (which is why reputations are salient but error-prone short-cuts cuts for decision-making). But also because the physician seemed oblivious about the last ten years of quality improvement research, and therefore a great opportunity (and responsibility) was missed to educate his patients that they are safer when harm is not hidden.

I get the reasons for defensive medicine. What I don't get is willing ignorance of life-saving improvements in one's craft. Is it time to bring competition down to the physician level? Should the public demand infection rates x MD?

Mark Graban said...

I published a podcast yesterday with Paul O'Neill (former chair of the Pittsburgh Regional Health Initiative) where he floated an idea that all hospitals should report all errors to the public, via the web, every morning at 8 AM - in the name of sharing and improvement, not for shame and blame purposes.

Provocative but probably not realistic, right?

Paul Levy said...

I've always admired Mr. O'Neill. He gets it.

Anonymous said...

Timely, Paul.

Going into hospital far riskier than flying: WHO

Didn't Steve Spears report this years ago?

WHO reports "Each year in the United States, 1.7 million infections are acquired in hospital, leading to 100,000 deaths, a far higher rate than in Europe where 4.5 million infections cause 37,000 deaths, according to WHO."

Mark Graban said...

@Anonymous, the famous Institute of Medicine report came out in 1999. O'Neill, in my interview of him, says the U.S. has made practically no progress on patient safety.

This isn't a technical and scientific challenge - it's a human challenge, a leadership challenge. Politics and ego get in the way (present hospital CEO company excluded!!!)

Anonymous said...

Great ideas from O'Neill and Graban. Which is more provocative - an airline type log or 100,000 preventable deaths? It is especially important that 'errors' not just 'harm' is reported. 'Errors' are more likely to be called out by subordinates in a hierarchy, while reporting 'harm' involving dominants requires great bravery in this job market. There is far too little research on obstacles to reporting, and the data will only be as good as the humans who volunteer it. I do occasionally make mistakes, but I certainly do not hurt anyone!

I'd love to wake up in the morning and read a quick log about my specialty rather than spend all day oblivious of some risk under my nose.

Paul Levy said...

Even before errors, near-misses contain a wealth of information. But people need to be trained and encouraged to call them out. Management needs to be trained to listen and hear respectfully and encourage call-outs. And then do root-cause analyses.

But as Brent James points out, you can't do real process improvement until you reduce variation in clinical practice. Why? You can't compare a proposed improvement to a "prior" unless a prior exists.

The theory is not new here. Womack and the other Lean people, Spear, Graban, et al, explain it clearly. Leadership needs to embrace this, though.

UPMC, which is a leader in so many ways, could enhance its reputation by learning and adopting and being transparent about its learning process.

Unknown said...

There will always be some errors - the real challenge in health care to develop the systems to not only prevent and report errors but support the very human people involved on both the provider and the family side.

Last year in Seattle - our leading regional Children's hospital reported 3 deaths due to "errors" and in one case the nurse involved was terminated and subsequently died from suicide.

One good resource is Medically Induced Trauma and their resource kits.

FYI - Prior to this event - I was the first and only patient to sit on our State Hospital Associations patient safety committee and it is critical to have patients voices present at the table when policies are developed around how to prevent harm and how to handle disclosure in a non adversarial way. But even I was harmed last year by a medical mistake.

AM said...

From Google+:

I wonder if what's needed is patient-centered malpractice reform. Something like creating a safe harbor with damage caps for incident responses that include transparency, disclosure, admission of wrongdoing, RCA, and process redesign to address root causes. I suspect such an approach would create better patient satisfaction, better safety and efficacy, and lower cost. Exceptions for gross negligence or criminal behavior, and penalties for coverups and CYA.

Paul Levy said...

Yes, good points, but here malpractice fears cannot be the issue, as the patient already knows of the error. This is a chance for UPMC to rise above the single case and help inform people throughout the field.

AM said...

From Google+:

Though I wonder if what's going on in this case is a refusal to investigate and improve the systemic issues involved because of fear that admitting the system was at fault opens UPMC up to wider liability.

Paul Levy said...

Ah, interesting thought. I'm not sure it actually would do that, but perhaps there is a fear of it.

Anonymous said...

I agree with AM. If they just keep quiet long enough and allow the accrediting agencies to support them in the blaming of specific professionals, then the system problems and accountability can remain unaddressed - less importantly the liability issue, but more importantly that they don't have to do the REAL work of system-wide process improvement that Paul addresses in his comments.
The temptation to find a scapegoat + a narrow, quick fix will only lead to another variation of error in the future. I saw this over and over in my own hospital-based practice.

You are right, Paul, to call them out to rise above the mediocre and become an example, as BID did with its own wrong site surgery.

nonlocal MD

Anonymous said...

This post is a bit obviated by the fact that the details have already been reported in the Pittsburgh post gazette. It was something about the system for their transplants didn't have the nephrologist having much involvement with the donors. The surgeon and coordinator were held responsible because the system they had gave them responsibility for the donor. I think part of the CMS-driven changes involved incorporating the nephrologist into the process earlier or something.

Anonymous said...

5:15pm But the post is about firing and one-off solutions, and the intimidating and limiting effects it has on improvement. Every harm that makes the paper gets an official explanation, but I can't imagine that this response will compel broader consideration of risk.

Terrific point, nonlocal MD. Regulatory bodies (and there must be many layers from specialty boards, boards of medicine, state, and federal) and representatives (hospital associations, physician associations, scientific associations) are complicit in perpetuating the prevalence of harm in medicine.

Perhaps these are points of pressure for patients. What percentage of board time/projects are devoted to transparency/safety? How many papers are presented at physician conferences on transparency, near miss reporting, safety innovation? Medicine is pretty amorphous. (That is why it is easy to blame it on an individual physician). A sitting regulatory or scientific board is not.

How many papers will there be at the next nephrology conference on quality innovation (that have something to do with human behavior)? How many will be presented by patients?

Scot said...

From Facebook:

I find it inconceivable that "nobody reviewed the record." I find it more plausible the record was so mission hostile, it went unnoted (see for example http://hcrenewal.blogspot.​ com/2011/05/transplant-tea​m-at-upmc-missed.html and http://hcrenewal.blogspot.​ com/2009/02/are-health-it-​designers-testers-and.html ).