Reduced work hours for doctors

In both Europe and the US, there has been a push to reduce the hours worked by doctors. This has been based on the belief that tired doctors make more mistakes. An article in this weeks BMJ points out that to date there is no evidence that these measures have brought about an improvement in safety. Why should this be? There are many possible explanations, but in my view, these reductions in working hours have been implemented without taking a fundamental look at how doctors work. in other words, a dramatic change in work hours should have been accompanied by a radical restructuring of shifts, handovers, continuity and so on. It is likely that this has not occured. The other problem is that junior doctors work hour and patterns evolved to match those of senior physicians. The work patterns of these senior doctors also needs to be considered and modified.

Boeing to the Rescue?

A recent piece in JAMA by Pronovost is well worth reading. In it he contrasts the way we design (or rather fail to design) healthcare, especially in relation to equipment, (haphazard, no systems thinking, individuals insisting on their preferred piece of technology etc) versus the way airlines buy planes. They do not buy planes, each of which has different toilets seats, lifebelts etc. They buy a standard plane, for economic as well as safety (reduce variation ) reasons. He suggests in an American context that what is needed is a systems integrator, similar to Boeing. It is interesting that national healthcare systems, despite being in a better position to act in this way, singularly fail to do so.
I have worked in intensive care units where the number of different types of ventilator exceeded the daily census of ventilated children; where the choice of a specific ventilator that a child was placed on depended on which physician was on call. This type of variability is hugely damaging, expensive, a safety risk and results in poor training. Compounding this is a perceived need for hospitals to get the latest new thing, often resulting in a situation where there are insufficient patient numbers to allow all team members to develop the required expertise and experience which are necessary to deliver the best outcomes.
While I agree with his arguments, I think he fails to develop the logical conclusion, in that the entire system, inside and outside hospitals needs to be standardized as much as possible.

Optimizing Patient Flow to enhance productivity and safety, Part 2

Coincidentally, following on from my recent post about patient flow, (March 16th) comes  a paper which again demonstrates the critical need to optimize patient flow, not just to improve productivity, but more importantly, to reduce mortality.
Just published this week is a very important paper in the NEJM, here. The authors looked at the effect of nurse staffing numbers on in-hospital mortality in a large academic hospital. It shows that peaks in patient flow (turnovers) are an even greater cause of mortality than patient per nurse staffing ratio. The authors state,
"We also found that the risk of death among patients increased with increasing exposure to shifts with high turnover of patients. Staffing projection models rarely account for the effect on workload of admissions, discharges, and transfers. Our results suggest that both target and actual staffing should be adjusted to account for the effect of turnover. In light of the potential importance of turnover on patient outcomes, research is needed to improve the management of turnover and institute workflows that mitigate the effect of this fluctuation."
The basis of this is simple. Elective admissions are hugely variable, and dependent almost entirely on doctor choice. Because these admissions occur without any reference to the other needs of the hospital, they cause huge peaks and troughs in patient numbers, e.g. not many elective patient will be admitted Friday.
One of the worlds leading experts in patient safety, Peter Pronovost, has also made clear his view that optimizing patient flow is essential for reducing in hospital mortality, see this recent paper.
There are huge opportunities to be had.

Progress of the Safety Movement

Some (relatively) disappointing news recently. An analysis of the Safer Patients Initiative was published in the BMJ (here and here). This was a large scale intervention comprising a large number of components of care. Unfortunately, there was no evidence of any difference in outcomes between control and intervention hospitals. What could the possible reasons be? There are a number of hypotheses,

1. hospitals will get safer regardless of interventions, and do not need this type of large scale change, (unlikely)
2. These interventions were too complex, encompassing 43 different interventions, (probable)
3. Management and clinician buy in, expertise, knowledge and support were insufficient to show a difference, (highly likely)
4. The interventions sought has insufficient evidence to underpin their use, (highly likely in some cases)
5. Many hospitals, (both intervention and control) already had high levels of quality in some domains, hence the big effects were less likely to be seen, (likely)

So what lessons can be drawn? I think there are a number.

1. Large scale change is difficult, messy, a long term commitment and often fails
2. Leadership, at management and clinical level is critical
3. Improvement and quality must be seen to be the only way to do business, not an optional extra
4. There must be a better system of measurement; even today measuring mortality is contentious. The ideal measurement system should be one that measures patient outcomes from the perspective of the patient, and reimburses the system, not a provider for optimal outcomes. See Micheal Porters work from Harvard for more on this

Safety and over the counter medications for children

A paper just published in JAMA provides some fascinating information about a lack of consistency in dosing instructions and measuring devices in over the counter (OTC) medications for children. the results are to say the least disturbing.


Results Measuring devices were packaged with 148 of 200 products (74.0%). Within this subset of 148 products, inconsistencies between the medication's dosing directions and markings on the device were found in 146 cases (98.6%). These included missing markings (n = 36, 24.3%) and superfluous markings (n = 120, 81.1%). Across all products, 11 (5.5%) used atypical units of measurement (eg, drams, cc) for doses listed. Milliliter, teaspoon, and tablespoon units were used for doses in 143 (71.5%), 155 (77.5%), and 37 (18.5%) products, respectively. A nonstandard abbreviation for milliliter (not mL) was used by 97 products. Of the products that included an abbreviation, 163 did not define at least 1 abbreviation.


Given that a major contributor to adverse medication events in children relate to dosing/ weight errors, obviously these discrepancies pose a potential risk. Of more importance, though it is not the subject of the paper is the efficacy and side effect profile of many of these therapies.

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.