Torture and Solitary Confinement

Not strictly medical improvement and certainly not seasonal, but a very powerful piece from Gawande just published in the New Yorker. Well worth a read.

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.

High Reliability Organizations

There has been a great deal of discussion recently about healthcare adopting the same approaches that have facilitated high reliability organisations to achieve exceptional levels of safety despite operating in high risk high consequence environments. Examples include aircraft carriers, nuclear submarines, the nuclear power industry and aviation.
What are the features of a high reliability organisation? Are these concepts translatable to healthcare? Are there any examples of HROs in healthcare?

There are according to one expert in the field five characteristics of HROs.

•Preoccupation with failure rather than success; this is self explanatory. The HRO almost celebrates failure and actively seeks it out recognising that only by recognising the defects within it's systems can it seek to rectify those defects.
•Reluctance to simplify interpretations; always seeking the explanation especially the explanation that defines the cause of a possible future mistake.
•Sensitivity to operations; To be sensitive to operations, we must monitor a messy reality and respond to the unexpected.
•Commitment to resilience; HROs recognize that not every risk can be mitigated, but anticipate failure and ensure that redundancy is built into the system.
•Deference to expertise; instead of hierarchy structures determining responses, the decision making in a HRO migrates to the persons with most expertise in that area.

The key difference between HROs and other organisations is that they respond differently to what others would consider signals of no significance. Mindfulness is what some have described this aspect, the capability to respond strongly to weak signals and respond strongly to mitigate the potential adverse consequences of such a failure. An example in healthcare might be the test result that is delayed, a routine test of no significance but this is a warning that the system is prone to error, that a time critical result may also be delayed. The HRO responds immediately to address this failure, the Low Reliability Organisation (LRO), effectively all of healthcare, is unlikely to take any action. HROs are constantly looking for evidence of failure or potential failure. Clearly these concepts can be applied to healthcare, though the details are likely to differ. However, it is likely that the only organisation which will successfully make this transition will be those in which the culture is receptive, indeed greedy, to make this change, and in which the leadership see becoming a HRO as the number one priority of the organization. This is such a fundamental shift that it likely that very few organizations will be successful in their attempts to become HROs.

I asked two physicians recently, world experts in safety and who lead the safety/ quality efforts in their hospital, which is probably the most advanced hospital in the world in this field, where their institution was on a 1-10 scale in safety. About a 3-4 on a good day they replied. That is the characteristic of a hospital that is striving to be the best and safest in the world, but recognises that despite being the best, it has a long journey ahead.

This book is probably one of the seminal works describing HROs, and I recommend it highly. Weick & Sutcliffe

IHI Forum

I am attending the annual IHI forum, in Orlando far away from the arctic conditions at home. Amazing stuff,  spending the day at a course devoted to paediatric patient safety, with talks from the worlds experts in this area. Steve Muething, Cincinnati Children's talks about developing a high reliability organization in healthcare. Matt Scanlon, Milwaukee, talks about human factors and measurements in paediatric safety. Anne Matlow, Sick kids Toronto talks about the major problem of diagnostic error in children, pointing out that diagnostic mistakes account for 13-20% of adverse events, but are more likely to be preventable and are more likely to cause serious harm or death. Paul Sharek, Stanford discussed medication safety, raising the provocative point that although a great deal of money has been devoted to improving medication safety,  medication errors account for 20% of all errors and a much smaller proportion of serous harm.

Influenza; Is cure better than prevention?

At a time when healthcare systems around the world are facing severe financial strain, it is worth asking whether there are any quick and dirty solutions out there. Amazingly there are, chief amongst them the ability to reduce the morbidity and mortality attributable to seasonal flu by the simple expedient of administering flu vaccine. The evidence base is not just strong, but strongly impressive. To take one example, a Swedish study published in 2001 found that recipients (aged >65 years) were half as likely to die from any cause in the year of vaccination, compared to their unvaccinated peers.
One measure of the cost effectiveness of any intervention is the cost per Quality Adjusted Life Year (QALY) saved. One conventional measure suggests that a cost per QALY of up to $50,000 is economically worthwhile. The cost per QALY for flu vaccine is -$17, i.e. for every patient vaccinated, there is a saving to the funder of $17. A no brainer. So how are we doing in Ireland? Recent data suggest that only 50% of people > 65 receive the flu vaccine.
So in answer to the question above, prevention is better than cure.

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.