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.