Patient safety

[LinksEtc]

I know a lot of my topics lately have been dancing on the edge of being FA related.  Please pm me if this is a problem.

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Tweeted by @ivanoransky

There’s an infection hospitals can nearly always prevent. Why don't they? vox.com/2015/7/9/89059… @sarahkliff w/help of @AHCJ fellowship

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"Do no harm
There’s an infection hospitals can nearly always prevent. Why don’t they?"
http://www.vox.com/2015/7/9/8905959/medical-harm-infection-prevention

A similar divide exists in modern medicine, when it comes to patient harm — especially for patient harm from central line infections. There are hospitals in the United States that view some level of central line infections as a sad but inevitable effect of putting thousands of these tubes into patients’ bodies each year. And then there are other hospitals that see each central line infection as a failure that requires investigation and better preventive techniques in the future.

In other words, there are car crash hospitals and there are plane crash hospitals.

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Tweeted by @picardonhealth

"How speaking up can save lives"
http://www.bbc.com/news/health-33544778

Aviation and medicine are two professions where the hierarchy that exists can make it particularly difficult for those lower down the pecking order to speak out.

He said: "It's quite unusual, a lot of people just back down after the first time you're not acknowledged. She was told quite bluntly to be quiet."

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Re: Docs helping patients to surf the internet

Tweeted by @hhask

"Nursing professor’s studies suggest ethics problem"
http://koin.com/2014/07/31/nursing-professors-studies-suggests-ethics-problem/

In Krautscheid’s view, her students were putting their relationships with doctors and senior nurses ahead of their responsibilities to their patients.

“How do we teach courage?” Krautscheid asks. “How do we teach backbone?”

“It’s easier just to go along and get along, and when you drill down on that through one-on-one interviews, what they tell you is, ‘I have to keep working with these people, and it seems to be part of the culture that this is OK,’” Krautscheid says.

[LinksEtc]

Tweeted by @RogueRad

"ProPublica aims to change the way you choose your surgeon. It could backfire. Here’s why."
https://drjengunter.wordpress.com/2015/07/12/propublica-aims-to-change-the-way-you-choose-your-surgeon-it-could-backfire-heres-why/

Here’s my concern. There are unnecessary surgeries and preventable complications. There are also necessary surgeries and unavoidable complications. Will their analysis of the data set distinguish between the two or is this just raw data?

Will the ProPublica data set control for diabetes, obesity, pre-operative infection, use of oral steroids and the thousands of risk factors that contribute to complication rates?

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Tweeted by @Gleason4plus5

@daviesbj @DennisG_Shea @charlesornstein @ashishkjha @jdimick1 I worry this would encourage unscrupulous drs/hosp to cherry pick their pts

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Tweeted by @AllergyKidsDoc

'Surgeon scorecard' measures docs by complications
http://www.usatoday.com/story/news/2015/07/14/surgeons-scored-in-new-online-tool/30083213/


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Tweeted by @FearLoathingBTX

"Secret deaths: CNN finds high surgical death rate for children at a Florida hospital"
http://www.cnn.com/2015/06/01/health/st-marys-medical-center/index.html

"Do you know a child with a heart problem here?" asked the stranger.

"Yes. My daughter," McCarthy answered, and explained what had happened to Layla.

"You need to get her out of here," the stranger warned.

[LinksEtc]

Surgeon Scorecard
by Sisi Wei, Olga Pierce and Marshall Allen, ProPublica, Updated July 15, 2015

https://projects.propublica.org/surgeons/

Guided by experts, ProPublica calculated death and complication rates for surgeons performing one of eight elective procedures in Medicare, carefully adjusting for differences in patient health, age and hospital quality. Use this database to know more about a surgeon before your operation.

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"What Experts Are Saying About Surgeon Scorecard"
https://www.propublica.org/article/surgeon-level-risk-quotes

Now that the scorecard is public, any expert who would like weigh in on our approach should send comments to: scorecard@ProPublica.org.

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"MAKING THE CUT
Why choosing the right surgeon matters even more than you know"
https://www.propublica.org/article/surgery-risks-patient-safety-surgeon-matters

The issue of patient safety has been at the forefront of American health care since 1999, when the Institute of Medicine released “To Err Is Human,” a landmark report on the startling frequency of medical errors.

But since then, medical errors haven’t abated — recent studies estimate that at least 200,000 patients a year die in hospitals from preventable errors and complications related to their care, which would make patient harm the nation’s third-leading cause of death.

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"Key Questions We Considered in Creating Surgeon Scorecard"
https://www.propublica.org/article/surgeon-level-risk-faq

15. Aren’t you worried the complication rates will be misunderstood by members of the public?

Online ratings have become a fact of modern life. Sites rate everyone from doctors to plumbers to massage therapists. Consumers are becoming increasingly savvy about using the Internet to do research on important decisions. We don’t think it’s beyond their intellectual abilities to understand and use Surgeon Scorecard.

[LinksEtc]

"Propublica’s #surgeonscorecard should be retracted"
https://medium.com/@justinmclachlan/propublica-s-surgeonscorecard-should-be-retracted-361055589f5a

 Propublica didn’t control for the fact that some doctors are fixers. They have a habit of taking on very complex patients or very difficult cases with inherently higher complication rates.

What Propublica is saying to the thousands of surgeons in their database, who’ve spent their entire adult lives in the sciences, is that we — an upstart of journalists — are so good at science that we don’t need your peer-review.

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"We have a better way, but it's secret"
http://runningahospital.blogspot.com/2015/07/we-have-better-way-but-its-secret.html?m=1

A number of experts and other folks have criticized the methodology used by ProPublica to indicate the relative rate of complications for surgeons across America.

There is a rigorous methodology available for evaluating surgical outcomes.  It is from the American College of Surgeons, and it is called NSQIP.

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"To Complain is Human"
http://jonessurgery.com/to-complain-is-human/

The article quite reasonably described concerns about individual surgeon performance, about transparency and the difficulties in normalizing data and interpreting results, and about the “captain of the ship” approach to surgery in both its faults and its benefits.

The methods, as usual, will be the most hotly contested portion of the study.

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From the Patients Are Smarter Than You Think Desk …
http://mightycasey.com/yelp-this-b-tch/

How about, rather than b**** about patients who want to serve up UX (User Experience) data on their clinical teams, you use your keyboard to help create some clarity on quality reporting that can be understood BY. AVERAGE. HUMANS.

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Real Stories: What One Medical Error Did To My Daughter
http://safepatientproject.org/story/what-one-medical-error-did-to-my-daughter

The physician responsible for prescribing Zomig never apologized or even checked in on her progress. Like many medical error cases, blame was pointed in many directions but little was ever done to properly correct and learn from the situation. It is horrific enough for a family to lose a loved one or watch a loved one’s life be destroyed by a preventable error, but that it continues to happen day after day, year after year, all across the country should be enough for this nation to demand better.

[LinksEtc]

Tweeted by @ashishkjha

My blog on the @ProPublica #SurgeonScorecard. Problems? Yup. Worth it? Absolutely. @marshall_allen @charlesornstein
blogs.sph.harvard.edu/ashish-jha/the…

"The ProPublica Report Card: A Step in the Right Direction"
https://blogs.sph.harvard.edu/ashish-jha/the-propublica-report-card-a-step-in-the-right-direction/

Because the choice wasn’t between building the perfect report card and building the one they did. The choice was between building their imperfect report card and leaving folks like Bobby with nothing.

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Tweeted by @Annakwood

"Don't Worry Your Pretty Little Head"
http://diaryofabenefitscrounger.blogspot.co.uk/2014/10/ok-this-really-has-to-stop.html?spref=fb

OK, this really has to stop.

I've written countless articles about the failure of doctors to listen to their patients. Whether that
failure comes from judgement (they're "just" an addict, they're "just" depressed, they're "just" malingering) or from arrogance (I know best, what would they know, I have the medical degree) I honestly believe it is the single most dangerous factor in our healthcare system.

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Tweeted by @Farzad_MD

"Doctors Tell All—and It’s Bad
A crop of books by disillusioned physicians reveals a corrosive doctor-patient relationship at the heart of our health-care crisis."
http://www.theatlantic.com/magazine/archive/2014/11/doctors-tell-all-and-its-bad/380785/

why it has become so difficult for so many doctors and patients to communicate with each other

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Tweeted by @hhask

'He's a Monster': Victims Blast Neurosurgeon Arrested For Allegedly Injuring Them
http://www.insideedition.com/headlines/11146-hes-a-monster-victims-blast-neurosurgeon-arrested-for-allegedly-injuring-them

A neurosurgeon has been indicted on assault charges over surgeries he allegedly botched.

[LinksEtc]

"Improving Diagnosis in Health Care"

The National Academies of Sciences Engineering Medicine

http://www.nap.edu/read/21794/chapter/1

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Mandatory reporting of diagnostic errors: “Not the right time?”
http://myheartsisters.org/2015/09/27/mandatory-reporting-of-diagnostic-errors-not-the-right-time/


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Tweeted by @kevinmd

"3 words that every doctor dreads: They changed this physician forever."
http://www.kevinmd.com/blog/2014/06/3-words-every-doctor-dread-changed-physician-forever.html?utm_content=buffer2b048&utm_medium=social&utm_source=twitter.com&utm_campaign=buffer

Emergency physician Brian Goldman, host of CBC’s White Coat, Black Art, wants to lift the
cloud of shame when medical mistakes are made, so they can be openly discussed and not be repeated by other physicians.

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Tweeted by @Paulflevy

1/2 It’s often said that we learn from our mistakes. But often not so true! athenahealth.com/leadership-for….

"Do we really learn from our mistakes?"
http://www.athenahealth.com/leadership-forum/really-learn-mistakes

We teach doctors about these cognitive weaknesses — anchoring, confirmation bias, and patterning — but we tell them that they are unlikely to recognize that they are happening. Instead, we need them to buy into systems of group behavior that protect them from themselves.

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Tweeted by @marshall_allen

Someone asked us for a study that showed the power of transparency. This one from the @theNPSF is pretty clear: npsf.org/?shiningalight

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"Shining a Light: Safer Health Care Through Transparency"
http://www.npsf.org/?shiningalight

Defining transparency as “the free flow of information that is open to the scrutiny of others,” this report offers sweeping recommendations to bring greater transparency in four domains: between clinicians and patients; among clinicians within an organization; between organizations; and between organizations and the public. It makes the case that true transparency will result in improved outcomes, fewer medical errors, more satisfied patients, and lowered costs of care.

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Tweeted by @trishgreenhalgh

"The wisdom of patients and families: ignore it at our peril"
http://qualitysafety.bmj.com/content/early/2015/07/22/bmjqs-2015-004573.full

A failure of providers to respond appropriately to the suffering that they have caused, a sense of abandonment, disrespect, a failure to listen, secrecy, long-term psychological and financial consequences were all key elements of the patients’ reports in the study. There was also a strongly expressed desire for openness and transparency, a long-standing aspect of the culture of healthcare worldwide that is too often lacking and that has led to calls for a statutory duty of candour or similar disclosure processes.

Yet, too often, this is seen as something to be ‘handled’ with a degree of wariness, or even worse, simply to be acknowledged with ritual expressions of regret rather than seeing it as part of the overall process of learning.

[LinksEtc]

Tweeted by @StanfordMedX

We're dedicating an entire day at #MedX to patient safety. Because patients deserve better. trib.al/78KUPvK pic.twitter.com/haoGpAJyri

http://medicinex.stanford.edu/safety/

harm reduction

design thinking

epatient engagement

safety needs

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Tweeted by @IgECPD

"DHB learns from allergy death"
http://www.newstalkzb.co.nz/news/health/dhb-learns-from-allergy-death/

80-year-old Eunice Richardson died after a nurse and registrar failed to check warnings on her MedicAlert bracelet, and was prescribed treatment that caused an allergic reaction.

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Tweeted by @woodrumlaw

"Any bite could be your last with a food allergy"
http://www.detroitnews.com/story/life/2015/07/28/bite-last-food-allergy/30804699/

Matthew was 7 when the next life-threatening scrape took place. He was in the hospital already for stomach surgery, and his mother put up a sign in his room regarding his allergy, she put a bracelet on her son and she told all the doctors, nurses and attendants.

It was the fortified whey in his hospital orange juice that got him.

[LinksEtc]

Tweeted by @HarvardBiz


"Why Organizations Forget What They Learn from Failures"
https://hbr.org/2016/02/why-organizations-forget-what-they-learn-from-failures?utm_source=twitter&utm_medium=social&utm_campaign=harvardbiz

In the aftermath of a serious error, an organization faces strong external pressures (e.g., from the public, from customers, from regulators), as well as internal pressures (e.g., the need to understand its causes and address its consequences) to learn from the mistake and avoid future similar ones.

Over time, though, several processes promote gradual forgetting

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Tweeted by @HeartSisters

"Medical Error. The Personal Cost"
Alison S. Clay
http://www.atsjournals.org/doi/full/10.1513/AnnalsATS.201307-227OT#.Vzjn2PD3arX

It looked like concentrated epinephrine for an intramuscular injection, but she hooked up the syringe to my IV.

I was angry about the errors I perceived: medication administered via the wrong route, a decision to extubate too early, the use of restraints without a way to “call” for help, a bed that was not elevated, an inexperienced provider intubating a complicated patient.

As a patient (and family), we are much more vocal about my care. We try to balance advocating without offending

[LinksEtc]

Re: Lala's DS-- passing a peanut challenge and REDEVELOPING the allergy

As far as I'm concerned, the patient experiences in this thread suggest under-addressed safety issues in how allergic symptoms following OFCs are handled by medical professionals.

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Drugs which are incompatible with allergy meds-- or RESCUE MEDS

Standard Protocol for "Asthma Action Plans"

Food Allergen Labeling: Using "common sense" when assessing safety




Feel free to add your own patient safety comments and/or links.

[LinksEtc]

"When a Brain Surgeon Becomes a Malpractice Lawyer"
https://www.propublica.org/article/when-a-brain-surgeon-becomes-a-malpractice-lawyer?utm_campaign=sprout&utm_medium=social&utm_source=twitter&utm_content=1455644829

I saw doctors and hospital officials cover up records, lie, not tell the patient and family what happened. I’ve seen fractures in the health care system, a lack of patient safety, and human nature and arrogance causing people to circle the wagons.

But everyone tries to not discuss what went wrong, to not expose themselves to a medical-legal situation or litigation. I think the self-interest of all the different groups has such control over who is supposed to do the regulation that there is just enough regulation for the public not to create a riot.

[LinksEtc]

No Room for Error

By Karen Nitkin and Lisa Broadhead; additional reporting by Linell Smith and Patrick Smith

http://www.hopkinsmedicine.org/news/articles/no-room-for-error?utm_medium=social&utm_source=Twitter&utm_campaign=PatientSafety&utm_term=NoRoomForError&utm_content=Dome

“The first thing I said to the Kings was that I was terribly sorry,” says Dover. “In those days, that was not fashionable. We told Tony and Sorrel we would find out exactly what had happened, we would communicate what we found and we would do our best to make sure it never happened again.”

"These events created a moral moment where we had to make a choice,” says Peter Pronovost, director of the Armstrong Institute for Patient Safety and Quality. “It was: Are we going to openly address our shortcomings? Or are we going to hide behind our brand and say all is well? Leadership stood up and said, ‘We need to start talking about this.’”

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"Why one top hospital is going public with its mistakes"
https://www.statnews.com/2016/05/03/brigham-and-womens-blogging-mistakes/

The current entries cover medication errors, delayed diagnoses, incorrect use of an intravenous line, and other problems that harmed, or could have harmed, a patient. Each article describes an error, how it came to light, and the steps taken to prevent it from happening again. When possible, it also includes comments from the patient who was on the receiving end of the error, and possibly his or her family members. The patient story is pivotal because it lets care providers understand how mistakes affect the lives of patients and their family members.

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"SAFETY REPORTING LEADS TO SAFER SYSTEMS"
https://bwhsafetymatters.org

If an error occurs once, it could easily happen again – unless it is reported. This is why we believe it is critical that staff speak up about all errors, even those that are caught before they reach a patient. When we are made aware of an error, we have the opportunity to examine what went wrong and change our systems to prevent future errors.

[LinksEtc]

"Hospital discharge: It’s one of the most dangerous periods for patients"
https://www.washingtonpost.com/news/to-your-health/wp/2016/04/29/from-hospital-to-home-a-dangerous-transition-for-many-patients/?postshare=8871462188012165&tid=ss_tw

“Poor transitional care is a huge, huge issue for everybody, but especially for older people with complex needs,” said Alicia Arbaje, an assistant professor at the Johns Hopkins School of Medicine in Baltimore. “The most risky transition is from hospital to home with the additional need for home care services, and that’s the one we know the least about.”

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Tweeted by @rvaughnmd


"Mom and dad often catch hospital errors doctors missed"
http://in.reuters.com/article/us-health-kids-hospital-mistakes-idINKCN0W224B

While the study is too small to draw broad conclusions on error rates or safety, it still highlights the value of parents speaking up when something seems amiss with their child’s care

“A parent knows their child better than any member of the health care team does, stands by their bedside and plays an active role in their child’s health care delivery throughout their hospitalization and after discharge, and often has a sense when something is not right,”