Posts Tagged ‘patient safety’

In 1999, the Institute of Medicine reported big risks in American hospitals.  Since then, there have been dedicated efforts to reduce those risks. Are things getting better? A recent New England Journal of Medicine article says no. You can more about the study with its author, Dr. Christopher Landrigan, on Getting Better Health Care.

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Medical safety — when can we be as good as the airlines?.

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Airline safety is remarkable.  USA Today reports that US airlines did not have a single fatality last year, the third year out of the last four with no air travel deaths. And that’s with U.S. carriers flying more than 10 million flights and hauling more than 700 million passengers.

Our automobile transport system isn’t that safe.  And how about our medical system? Sure, many deaths can’t be prevented by medical science, but wouldn’t it be great if we were to read a headline sometime soon that reads, “Medical System Documents a Year with No Preventable Deaths” or “No Wrong Site Surgery in 3 of the Past 4 Years”?

Airlines can do this, as there is a system in place for measuring and reporting.  The American medical non-system doesn’t even have a mechanism in place for assessing how many deaths, wrong site surgeries or other major safety issues occur, much less a system for reporting the number or a systematic approach to achieving 100 percent safety.

We may be heading in that direction, though.  Data collection and dissemination continues to get easier and less expensive.  If we can start a website that lets all patients rate their satisfaction with all doctors, we should be able to create reliable safety reporting system.

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The Washington Post reports that the FDA may try to recall a device that was approved for repairing damaged knee joints.  The report says that the device was originally approved with little testing under rules that allow fast-track approval for products that are similar to other products already on the market.

Apparently FDA scientists thought more testing needed to be done, but the product was approved because of political pressure.

The FDA has a tough job.  It has to assure the efficacy and safety of new drugs and medical devices.  But there’s no way to show that anything is completely safe.  There has to be a balance between assuring safety and making products available to help patients in need.

I don’t know how much need there was for this knee joint replacement product.  It may be that getting it to market quickly helped far more people than it hurt.  Ideally, though, it would be good if objective decisions about benefits and risks could be made without political interference.  But it’s also important that the folks at the FDA not be allowed to spend too much time and resources assuring safety if in doing so they block patients’ access to helpful new treatments.

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Sometimes, there is  not one right answer to the problems faced in medicine (or in any other field).  For example, we want drugs that have awesome efficacy.  We want drugs that are extremely safe.  We want drugs that are affordable.  It’s not likely we’ll get all three (or even two of the three) at once.

Providing the best information about prescription medications to patients is another conundrum.  As pointed out in a recent publication (Winterstein AG, Linden S, Lee AE, Fernandez EM, Kimberlin CL. Evaluation of consumer medication information dispensed in retail pharmacies. Arch Intern Med.  2010;170:1317-24), the law requires that most prescriptions be accompanied by useful written consumer medication information.

But what does “useful” mean exactly?  Putting together a “useful” handout that is readable and has the basic information is certainly going to help patients, but it is also presents a risky situation for the manufacturer.  Of course “useful” information includes material that is understandable and necessary to understand and correctly use the medication.  But should every side effect be included?  Where do you draw the line between side effects that are common and those that are too rare to include?  And if you do exclude any, how would patients feel if they developed a known rare side effect that was left out of the brochure?

National Public Radio quotes Joe Graedon — a pharmacologist, host of the People’s Pharmacy and an expert on practical drug information — as saying that there are only a few key things people really need to know about their drugs:

  • how to take the drug
  • the most common side effects
  • symptoms to watch out for and what to do if they happen

That’s sensible advice.  However, there are many of lawyers out there — you’ve seen their ads on TV.  With so many of them around, how will people justify excluding information for patients  about even the rarest of risks, and making the brochures so long and so technical that they are no longer considered “useful?”

Note: I have been a big fan of  Graedons’ Peoples Pharmacy program for years and have been a guest on the show a few times.  You should check it out here. It is a terrific medical resource.

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I received an e-mail invitation to attend a medical-legal seminar on reducing risks. I’m not sure what they are going to cover, but clearly, the No. 1 way to reduce medical legal risks is for doctors to give patients great quality medical care. Patients also need to perceive the quality of care is great. That is why obtaining feedback from a patient satisfaction survey service like DrScore is a necessary component to assessing and assuring patient satisfaction.

Great medical care is really a partnership. Patients can reduce their risk of being in the kind of situation that results in medico-legal liability by taking more responsibility for their own care. Patients should get a copy of their medical records, particularly the results of laboratory work that is done. That will help make certain nothing falls through the cracks in a system that has shown itself to have too many cracks.

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DrScore.com is a great way for patients to give feedback and to look up doctor ratings. But there are more traditional ways to assess and assure doctor quality: board certification. I discuss board certification with Dr. Kevin Weiss, president and CEO of the American Board of Medical Specialties on Getting Better Health Care. You can find out whether your doctor is board certified at http://abms.org/.

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In my last blog, I pointed out that doctors’ overall patient satisfaction scores are very dependent on how often patients are completely dissatisfied. Even if there are only a few highly dissatisfied patients, it can lower a doctor’s patient satisfaction score considerably. And that’s the least of the problems with unhappy patients.

Leaving patients feeling uncared for and dissatisfied increases doctors’ risk of being sued for malpractice. These unhappy patients may also share their poor experiences with their friends, hurting the doctor’s (and all doctors’) reputation.

Worse yet, these dissatisfied patients are at risk for having poor outcomes. Poor outcomes leave patients angry and disappointed, and leaving patients angry and disappointed results in patients having poor outcomes. I think this is probably because these patients are less likely to use their medications. Since our goal as physicians is to get patients well, we also need to make sure our patients are satisfied with their care.

But the biggest problem of all with having unhappy patients is: having unhappy patients. We didn’t spend all those years in training because we don’t care about our patients. We care deeply about them. If they aren’t happy, neither are we.

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Just finished reading Dubner and Levitt’s book Superfreakonomics. It is an entertaining follow-up to their most excellent first book, Freakonomics. Among the eclectic topics in Superfreakonomics is their work on the quality of emergency room (ER) doctors —finding that the likelihood of surviving a trip to the ER depends less on which doctor a patient sees and far more on other factors including patient demographics and condition.

The great majority of patients survive the ER. Dubner and Levitt report that estimates of doctor quality suggest that the quality of the doctor might affect the low death rates by 10 percent. On the positive side, 10 percent of an already very small number is a small effect indeed, so that even average doctors are doing a very good job. On the “glass is half empty” side, over the thousands of patients seen each year in the ER, the difference in quality will end up in a few lives lost, and each one is significant.

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Another of the highlights of Nance’s book Why Hospitals Should Fly involves the importance of unambiguous communication and the need to seek clarity from others. The line that really caught my attention was, “I know you think you understand what you thought I said, but I’m not sure if you realize that what you heard wasn’t what I meant?”

All too often, in medicine and in life, miscommunications occur. When we say something, it comes from the context in which we are currently thinking. The receiver of the message may interpret the words in some completely different context. This can result in dramatic degrees of miscommunication between health care professionals and between physicians and their patients. These kinds of miscommunications are one element discussed in my book, Compartments: How the Brightest, Best Trained, and Most Caring People Can Make Judgments That are Completely and Utterly Wrong (www.compartmentsbook.com).

Nance points out that we should listen to people repeat back what they said to us. That’s one helpful approach. Having a buddy come with the patient to record key points is another. Written instructions may be the most valuable way to assure good communication between doctors and patients.

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