Posts Tagged ‘Bob Wachter’
Just over ten years ago a report by the Institute of Medicine, a branch of the National Academy of Sciences, more or less launched the patient safety movement with its estimate that medical error was responsible for something like 50-100,000 deaths annually. That’s a chilling statistic. It’s also one that has been disputed as overblown. But overblown or not, since then all hospitals have made intensive efforts to make them safer places for patients, using things like checklists, time-outs before procedures, and many other simple but crucial things to make sure we are doing the right thing to the right patient. So how are we doing? Are hospitals any safer than they were a decade ago?
Dr. Bob Wachter, one of the gurus of the patient safety movement, recently assessed where we are. His answer is no worse at least, probably a bit better, but not dramatically better. You can read his very informed opinion about it here, on the Health Care Blog. His essay is in response to a sobering study that suggested we haven’t made much meaningful progress in the patient safety field. Bob agrees that it’s disappointing we haven’t managed to make things better more quickly. Overall, though he thinks that we’ve turned the corner on patient safety and are at least steadily moving in the right direction. The fundamental problem is that, well, safety is hard.
A lot of this research is with adult patients, not children. My own opinion is that the PICU is, in fact, a safer place than it was a decade ago. Where I wrk, we are using checklists for common PICU procedures, such as placement of central venous catheters. We are methodical and stringent about looking for signs of skin sores in bedridden PICU patients. Our physician order entry is now all computerized, and the computer regularly picks up problematic orders, things like potentially unsafe drug interactions duplicate orders. Once I got used to it (which took a while) I found that I much prefer physician computer order entry to the old way — writing orders out on paper.
So I’m with Bob; I think hospitals are safer places than they were 10 years ago. We still have a long way to go. The most important thing the patient safety movement has taught us is to take a systems approach to error prevention. Because, as the Institute of Medicine titled their landmark study: “To err is human.” Bob summarizes it this way:
But we’re coming to understand that to make a real, enduring difference in safety, we have to transform the culture of our healthcare world – to get providers to develop new ways of talking to each other and new instincts when they spot errors and unsafe conditions. They, and healthcare leaders, need to instinctively think “system” when they see an adverse event, and embrace openness over secrecy, even when that’s hard to do.
Ten years ago a report by the Institute of Medicine, a branch of the National Academy of Sciences, more or less launched the patient safety movement with its estimate that medical error was responsible for something like 50-100,000 deaths annually. That’s a chilling statistic. It’s also one that has been disputed as overblown. But overblown or not, since then all hospitals have made intensive efforts to make them safer places for patients, using things like checklists, time-outs before procedures, and many other simple but crucial things to make sure we are doing the right thing to the right patient. So how are we doing? Are hospitals any safer than they were a decade ago?
Dr. Bob Wachter, one of the gurus of the patient safety movement, recently assessed where we are. His answer is no worse at least, probably a bit better, but not dramatically better. You can read his very informed opinion about it here, on the Health Care Blog. He thinks that, overall, we’ve turned the corner on patient safety and are at last moving in the right direction.
A lot of this research is with adult patients, not children. My own opinion is that the PICU is, in fact, a safer place than it was a decade ago. We are using checklists for common PICU procedures, such as placement of central venous catheters. We are methodical and stringent about looking for signs of skin sores in bedridden PICU patients. Our physician order entry is now all computerized, and the computer regularly picks up problematic orders, things like potentially unsafe drug interactions duplicate orders.
So I’m with Bob; I think hospitals are safer places than they were 10 years ago. We still have a long way to go. The most important thing the patient safety movement has taught us is to take a systems approach to error prevention. Because, as the Institute of Medicine titled their landmark study: “To err is human.”
A few months ago I wrote about the issue of knowing if your child is in a good PICU or not. Recently the federal Department of Health and Human Services began the first halting steps toward allowing ordinary citizens to compare easily how different hospitals perform — they put up an easy-to-use website that lets you compare up to three hospitals at a time with a couple of simple mouse clicks. The site is here. The Commonwealth Fund also has begun a project, aptly termed “Why Not the Best,” that you can find here. The notion, of course, is that transparency of this sort will allow smart healthcare consumers (who in simpler times we called patients) to shop around for hospitals with the best outcomes. There are at present, however, several serious problems with the notion.
One problem is that the data don’t really tell you much about outcomes, which is what we really want to know. Rather, the sites mostly concern process. That is, it measures how many patients received a particular treatment recommended by the experts for a particular condition. The assumption is that if the accepted, correct process is followed, things will turn out better for the patient. This is only an assumption, and it carries with it the possibility that hospitals will be vigilant only about process measures. In effect, they may “teach for the test” mainly to make themselves look good. The only outcome statistics are death rates for three conditions (all in adults) — heart attacks, heart failure, and pneumonia. And they don’t give you the actual numbers, just if the hospital was significantly above or below the national average.
Another issue, one Dr. Bob Wachter well discusses on his excellent blog here, is that no one is paying any attention to these statistics anyway. Most people still choose their hospital based upon recommendations of friends and doctors — word of mouth.
In the long run, though, the site is an example of what is coming in the future. One day hospital performance will be out in the open for all to see and evaluate. Although there is virtually nothing available yet about children’s hospitals (and their PICUs), this, too, is probably coming.
I’ve written before about medical errors. Recently there was a horrendous one, in which a man in Boston got an operation on the wrong part of his body. Other than underscoring the fact that humans are fallible, what can we learn from this terrible incident?
There are supposed to be safeguards in place to prevent this kind of thing from happening. The process can best be summarized as confirming the answers to these questions: Are we doing this to the right patient, doing the right procedure, and doing it in the right place? Clearly this ‘time-out’ step was not done in this case. The result was tragedy.
The CEO of the hospital immediately admitted and evaluated the error here. It makes interesting reading. He admits the error, but he also makes oblique excuses for it, citing how chaotic and pressured the environment was, implying that somehow lessons the culpability.
The problem with that, as Dr. Bob Wachter explains on his excellent blog, is that we should plan for chaos and a pressured environment. It’s the way things always are. Dr. Wachter is a noted authority on patient safety issues. He uses examples as varied as the airline industry and service at the International House of Pancakes to emphasize that we certainly can devise systems that protect individuals — both the patients from harm and the doctors from ourselves.
Two-thirds of all internet users do Google searches to look for health information. So we shouldn’t be surprised that Google is entering the world of healthcare in a big way. A couple days ago Google Health went live. It’s still only in a beta version, but users can already give it a test drive. So what is it, exactly?
The fundamental notion is that it gives the patient, the consumer, access to (and therefore control of) the health record. A user can store in one spot all information about his health — medical records, laboratory test results, pharmacy records, and even general information about his health conditions. This last aspect is key. Your Google Health site can be a central repository about what your health needs are, what’s been done about them, and what you might or should do about them. Of course for the whole thing to work most third-parties, like hospitals, pharmacies, and doctors’ practices, have to sign on to participate. More fundamental than that, medical records need to be totally electronic so users can upload them, and at this time many, even most, are not — they’re still on paper.
Google also plans to do more than just be a search engine. Through its Knol project, it means to be a source of hard information about health issues with a whole library of signed articles by experts. I was one of the medical experts Google asked to help launch the project, which should go live later this year. I think it will be a very useful site and will generate a huge amount of traffic because all of the contributions are signed by people whose credentials you can check. It also will allow comments by readers.
One major concern about Google Health is how secure your personal health information is, and if Google (or anybody else) will use it to target marketing initiatives at you. Google says they are taking extra precautions to secure the data, but this is a serious concern. Also, as of now there is no advertising on the site, but there could be in the future. I would be concerned if Google used your personal health record to select ads targeted at you, as they do now according to what you search. You can read a general news story about the project here and an insider’s description by Dr. Bob Wachter here.
Edited to add: here’s another excellent review of what Google’s entry into healthcare might mean. It’s from Lynch Ryan’s Workers’ Comp Insider blog, and it weighs both the pros and the cons.
All of us have the expectation that our medical records, those personal things about us and our families, are safe from prying eyes. Federal law (HIPAA) protects our privacy and mandates quite strict standards, leading to all those forms you have to sign when you go to the doctor. In these days of the electronic medical record, how safe are those records? As I type this I could, if I so chose, call up on my computer the personal details of every single patient in the hospital. What’s to keep me from doing that? Not much, it turns out, other than my own conscience.
A recent story in the Los Angeles Times, discussed in detail on Dr. Bob Wachter’s excellent blog, shows that, for many people, the temptation to snoop was too much: when Britney Spears was recently in the UCLA hospital, a total of 53 hospital staffers inappropriately looked at her record, 14 of them physicians. Perhaps the bigger scandal is how the miscreants (and all of them knew they were violating both HIPAA and UCLA policy) were treated: none of the doctors were fired, half the nonphysicians were sacked, raising the question of equal treatment for the same crime.
This is not a new problem, of course. I spent much of my career at the Mayo Clinic, an institution well-known for decades for its famous patients, and where the charts of those people were kept well protected. Of course it is relatively easy to guard a physical record, a folder of paper; the electronic medical record is a different matter. Although I am all in favor of the electronic version, this case tells us we must take great pains to secure the data. The case also suggests we don’t treat doctors and nurses the same, and as Dr. Wachter says, that’s not right.
All of us have the expectation that our medical records, those personal things about us and our families, are safe from prying eyes. Federal law (HIPAA) protects our privacy and mandates quite strict standards, leading to all those forms you have to sign when you go to the doctor. In these days of the electronic medical record, how safe are those records? As I type this I could, if I so chose, call up on my computer the personal details of every single patient in the hospital. What’s to keep me from doing that? Not much, it turns out, other than my own conscience.
A recent story in the Los Angeles Times, discussed in detail on Dr. Bob Wachter‘s excellent blog, shows that, for many people, the temptation to snoop was too much: when Britney Spears was recently in the UCLA hospital, a total of 53 hospital staffers inappropriately looked at her record, 14 of them physicians. Perhaps the bigger scandal is how the miscreants (and all of them knew they were violating both HIPAA and UCLA policy) were treated: none of the doctors were fired, half the nonphysicians were sacked, raising the question of equal treatment for the same crime.
This is not a new problem, of course. I spent much of my career at the Mayo Clinic, an institution well-known for decades for its famous patients, and where the charts of those people were kept well protected. Of course it is relatively easy to guard a physical record, a folder of paper; the electronic medical record is a different matter. Although I am all in favor of the electronic version, this case tells us we must take great pains to secure the data. The case also suggests we don’t treat doctors and nurses the same, and as Dr. Wachter says, that’s not right.
Sachin on 