Preventable Harm, Redux

A commentary by the authors of the NEJM paper I referred to recently has just been published. Well worth reading.

Diagnostic Error; The Elephant in the Closet?

Diagnostic error as a cause of avoidable harm has received relatively little attention in the quality safety literature until recently. Diagnostic error is a diagnosis that is missed, delayed, or incorrect. Various estimates suggest that errors of diagnosis account for 40-80,000 deaths annually in the US. Autopsy studies have shown that in 5% of cases, a diagnosis is found which if known prior to death and treated appropriately could have averted death. Physician errors are more likely to occur from diagnostic mistakes than medication error; are likely to result in serious harm and more likely to result in bigger lawsuit payouts.  The causes of diagnostic error are complex, and as yet poorly understood. One concerning finding however is that a lack of knowledge or expertise is rarely the rimary factor; indeed, some researchers suggest that experienced doctors who have "a gut feeling" may be led astray by their experience. For further reading, I would suggest this paper by Pronovost. A talk at the recent Risky Business conference which discussed the psychological basis of error is well worth viewing. (Free to view, but registration required)
There are few data in paediatrics; a recent study reported that 50% of paediatricians had made one to two diagnostic errors in the previous month. 45% reported diagnostic errors that harmed patients at least once in the previous year.
So we have identified a big problem, conceivably more serious than medication harm; what is the solution? In truth, no-one knows. Suggestions include computer aided diagnostic tools, realistic simulation in training, more training!, reform of tort law. We need to start with the basics, and begin to understand the causes of diagnostic error, and only then can we begin to introduce solutions. Medicine is messy, diagnosis in contrast to treatment remains an art; we have to make it more of a science.

Preventable Harm in Hospitalized Patients

Following on from my recent discussion about the use of trigger tools, a paper just published in the New England Journal reports the rate of preventable harm occurring in patients admitted to 10 North Carolina hospitals over a 6 year period. The authors used a validated trigger tool to analyze charts from 100 admissions per quarter.
The results are very alarming; despite a reputation as being a state that is very proactice in efforts to reduce harm, there was no reduction in harm over the study period. For every 100 admissions, there were 25 episodes of harm. It is important to point out that not every one of these episodes caused serious harm. 18% of patients were harmed as a result of medical care. 63% of these episodes were considered to be preventable. Of the harm episodes considered to be preventable, 26% caused permanent damage, were life threatening or caused or contributed to a patient death. overall 2.4% of harms caused or contributed to a patients death.
The most common errors arose from procedure complications, hospital acquired infections and medication errors.
This paper is a wake up call for the patient safety movement; despite much apparent and real progress over the past decade, it is a cause for concern that there has been no significant improvement in patient safety. There are likely many reasons for this; patient safety has not been a research priority, safety always involves a cultural shift within in heathcare which can be very difficult to achieve, and by not involving the younger generation of healthcare professionals, especially at their training stage, we are adding to the difficulty.

Toy Related Deaths in Children

There has been a reduction in the number of deaths of US children in 2009; 12 deaths vs. 24 deaths in '07 & '08. Riding toys are associated with approx. 50% of deaths, usually when the child rides into a ditch or pool and drowns. There were almost 200,000 injuries related to toys treated in US emergency rooms last year. A good excuse to cut down on toy expenditure this christmas or concentrate on jigsaws. Link

More on Checklists

Paul Levy writes in his oustanding blog about checklists, making the very relevant point that the checklist per se is not a panacea; it is one ingredient in a very complex system that contributes to safety.

Treatment of Otitis Media

A meta-analysis just published here reviews the diagnosis, microbiology and treatment of acute otitis media (AOM) in children. I have always been surprised by the low numbers of kids with AOM I see, compared with the reported prevalence. The results of this paper were quite interesting; the presence of a bulging tympanic membrane and redness of the membrane were associated with a positive diagnosis. nothing surprising there.

Following the introduction of heptavalent pneumococcal conjugate vaccine (PCV7), Streptococcus pneumoniae decreased, while that of Haemophilus influenzae increased.

The authors concluded, "otoscopic findings are critical to accurate AOM diagnosis. AOM microbiology has changed with use of PCV7. Antibiotics are modestly more effective than no treatment butcause adverse effects in 4% to 10% of children. Most antibiotics have comparable clinical success."

Trigger Tools

How should we measure the harm we cause in healthcare? One method, increasingly widely used, is a trigger tool. These are standardized and validated instruments with which one reviews a random selection of medical charts; when a "trigger" is identified that might signal a possible harmful occurrence, the chart is reviewed in more detail to determine whether harm did occur. There are two benefits; an organisation can measure the harm it is causing over time and take steps to reduce the harm, and second, measure its effectiveness in reducing harm over time. In contrast to conventional incident reporting, the rate of harm detected by these tools is 2-5 fold higher. For more reading, I would suggest the following; IHI and NHSIII

IHI Model for Improvement

Am attending and speaking at a forum hosted by HSE and Clinical Indemnity Scheme which is discussing the Heartbeat Scheme. Apart from the specific cardiovascular theme, Noeleen Devaney, a former IHI fellow is discussing the IHI Model for Improvement. She makes the critical point that this methodology can be applied to any problem in healthcare, clinical and non-clinical. Such an approach is critical to empowering front line staff, improving quality, and improving work satisfaction. For more information I would suggest checking out this section of the IHI website.

Medical Error in the White House

A recent article in the New York Times describes the experiences of a physician whose job was to be Physician in Chief to the sitting US president. It contains some fascinating nuggets; "White House doctors have erred. Air Force One carries antibiotics and other drugs, as well as several pints of blood reserved for the president and first lady. In 1994, when Mr. Clinton was planning a foreign trip, Dr. Mariano wrote, Dr. Bob Ramsey, an Army colonel and a blood specialist in the White House medical unit, gave doctors at the host hospitals the wrong blood type for the president, a potentially fatal medical error, and Dr. Ramsey was fired."

Change Concepts

An interesting look at "change" from a leading Harvard Business School Professor.

Ethics of in flight CPR

Interesting article in this weeks New England Journal. My anecdotal impression is that there is a disproportionate need for doctors on flights, usually for minor ailments but not unusually for major problems. This article describes this occurrence from an unusual perspective, that of a medical ethicist. www.nejm.org

Risky Business

One of the most exciting, stimulating, thought provoking events in the calendar. The idea is to promote a different way of seeing healthcare, by invoking parallels from other industries, occupations, walks of life. It is in equal measures exhilarating, thought provoking, sad, and optimistic. The varied speakers show how one can overcome adversity, achieve excellence, and succeed in the most challenging conditions. On the other hand, some speakers can almost bring one to tears with their descriptions of adversity and hardship; the daughter of a Tory MP killed in the Brighton bomb speaking on stage with the former IRA member who planted the bomb; the cardiac intensivist describing the trauma of litigation following the death of a child, the Canadian physician who demonstrates the weakness of our thinking patterns which lead us to cause mistakes. Well worth checking out. Risky Business. Registration is free. The highlights for me were the first day, devoted to paediatrics, not available to view. The evidence shown from Cincinnati Childrens demonstrating the effectiveness of their drive to zero harm was outstanding.

Checklists

Since the study published two years ago in the New England Journal of Medicine by Gawande, which showed the value of checklists in reducing surgical morbidity and mortality in a variety of care settings, developed and developing world, there has been increasing interest in the benefits of checklists in improving patient safety. However the Gawande study has been criticized on a number of fronts, with many people doubting the benefits. The cardinal message of that study was that each of us, no matter how brilliant, will make mistakes. The purpose of the checklist is to reduce the risk of each team member making a mistake. Importantly, two major studies have just been published, which support Gawande's contention that the use of checklists are associated with improved outcomes. De Vries et al writing in the NEJM report a dramatic reduction in mortality and complications.

Neily et al writing in JAMA last month report similarly impressive results. It would appear that the jury is in; the use of checklists as part of a comprehensive approach to reducing surgical complications appears to be proven. Let the checklist reign.

First Post

Welcome. The purpose of this blog is to share the latest happenings, events, news in the area of patient safety to an Irish audience. There are many healthcare workers interested in and committed to improving safety and quality in Irish healthcare, but they are faced with numerous problems in trying to develop their expertise and interest, including a disempowering management structure, lack of awareness of others in the system with similar interests and an absence of training in the area of the Science of Improvement.

I hope to post on a regular basis, and include news, links, ideas etc in order to stimulate discussion about patient safety.