Posts Tagged medical errors

Global Health Care — an edX course

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So you think your health system is bad?  There are countries where doctors and nurses leave due to the risk of death (their own), countries where health care workers can’t make enough money to pay for their own hospital care, countries that don’t keep medical records, countries where doctors must see at least 100 patients per day and countries where a patient purchases the number of questions they want a doctor to ask — one question is typical — and at very low cost!

As the author of this blog I decided to try an online learning course from edX titled “Improving Global Health: Focusing on Quality and Safety” presented by faculty at Harvard.  Overall it is a good course.  I am sure everybody who takes the course finds different parts interesting depending on where they live and their background in health care quality and system organization.

Below are the things I found interesting from a US healthcare perspective:

  1. Errors and harm caused by health, especially in hospitals, is high everywhere.  The big categories are hospital acquired infections, adverse drug events, falls with injury, surgical complications, pressure ulcers and deep venous thrombosis.  Significant harm happens in about 10 to 15% of hospitalizations.  Errors in medical/surgical management are considered preventable.
  2. Countries have different standards of care.  And, countries have different legal systems.  The most interesting concept is to eliminate malpractice suits by having a compensation board and strong quality improvement.  Thus, patients get compensation much faster and the health care system improves to mitigate errors.  Accountability for errors becomes part of the quality improvement process, not the legal system.
  3. In most countries hospital and outpatient care seem to be in different silos, much to the detriment of patients who transition between the two.
  4. The PLAN-DO-STUDY-ACT cycle is critical to quality improvement.
  5. “If you can’t measure it, you can’t improve it“.  But, high tech and computerized methods are not always needed.  In low and middle income countries the use of simulated patients (in the US called secret shoppers) and text messaging questions by cell phone can collect hugely important data with a minimum of cost.
  6. Management practices of business in general are more effective than the business practices in healthcare.   The same principals apply and need to be followed.  For example, managers not meeting expectations need to be changed.  Just like measurements of healthcare quality there are measurements of business quality.  A culture of blame is a big problem.
  7. Patient-centered care is critically important.  There is a very strong statistical link between patients who feel their needs are being met and almost all other technical measures of quality.  Simply asking patients what they expect is a huge first step that is not being done my a majority of providers.  Dignity, respect and putting effort into meeting expectations is the essence of patient-centered care.  One measurement of patient-centered care is waiting time — waiting time for making an appointment, waiting time in an office, and waiting for surgery.
  8. Universal healthcare is highly desirable and some countries do a better job than others.  The key features are:  enrollment (signing up and getting a health card), universal coverage (the funds to pay for care — like insurance), and finally effective application of the coverage.  The last element is actually “quality” healthcare.  Having a health card is not enough.  Having insurance is not enough. Effective care is a combination of prevention (population-centered) and patient-centered care within the financial constraints of a system.
  9. Politics is present in all forms of health care.  But, the focus for patients, providers and the news media should be on the gap between care that is reasonably possible and care that is actually delivered.

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U.S. Malpractice System is a Failure

Cut the ribbon

The U.S. tort system as a solution to compensation for medical errors is an abysmal failure.   It’s unfair to doctors and  it’s unfair to patients.

Here are a few statistics to make the point:

  • Every year 400,000 patients are killed by medical errors and even more are injured.  But, less than 2% receive compensation through suits.  98% never file suits.
  • 80% of suits against doctors fail.
  • 50% of compensation awards are paid to lawyers.
  • The average time from filing suit to winning compensation is 3.5 years.

The practice of “defensive medicine” is well known.  The fear of suits has caused many doctors to order more tests than are necessary.  Even the AMA estimates the unnecessary tests cost between $84 and $151 billion each year.  Worse yet is the effect on medical records:  doctors make records “look good in court” by leaving out embarrassing details — making the job of quality improvement much more difficult.

There can be no other conclusion:  the U.S. justice system is incapable of providing compensation to the vast numbers of injured patients and it stands in the way of quality improvement.

Other countries have much better systems.  One that really stands out is Finland.  They have separated compensation from accountability and quality improvement.  Compensation is decided by a compensation board — compensation is often paid in as little as 2 weeks.  Physicians can readily admit an error and say “I’m sorry” and go a step further and actually help patients get compensation.  

The Fins have a strong quality improvement program which can change the medical system that allows errors to happen and force practice changes as needed — the primary goal is to reduce errors, not to punish doctors (except for criminal behavior). 

The money spent in the  U.S. for malpractice insurance both by doctors and hospitals, and the fees for lawyers would be much better spent in a compensation system like Finland.  Current efforts at U.S. “tort reform” are aimed at reducing suits and thus reducing compensation.  The suits remain unfair to doctors and inadequate to serve injured patients.  “Tort reform” should be changed to “tort elimination” then replaced with a compensation board type system.

This is an excellent time to change the tort system because the U.S. is on the verge of universal health insurance.  The question of who will pay the cost of health care error  is “insurance” rather than bankruptcy court.  By setting up a compensation system more attention can be directed to fair compensation and much stronger quality improvement.

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Dermatology — prices that get under your skin

skeratosis

Elisabeth Rosenthal reported “Patients’ Costs Skyrocket; Specialists’ Incomes Soar” in the New York Times today 1/19/19.  She particularly targets one of the most popular specialties for US trained physicians, dermatology.  Good hours, great pay, and compared to other specialties, easy to learn.

A highly trained thoracic surgeon can only do 2 bypass surgeries per day but a dermatologist can to 20 lesion removals per day and make almost as much money.   Patients choose to go to a dermatologist when most primary care doctors can just as easily solve the problem at a fraction of the cost (like benign skin lesions, sun related pre-cancers, and acne).  And, when infection sets in on the weekend the dermatologist’s answering machine says to  go to the emergency room ($300 co-pay).

She describes a situation where a woman had a facial skin cancer removed at a cost of $26,014.   The astounding cost was the result of a dermatologist removing a lesion and then being unable or unwilling to close the wound — but still billing for the procedure.  And, the patient also received bills from the doctors that actually fixed the problem (perhaps they should have billed the dermatologist).  Sadly, a bad system is more profitable than a good system.

It is easy to see why the patient and Ms. Rosenthal believe there is a problem with US healthcare.   Because, THERE IS A PROBLEM!

Rather than complain about the problem, what is the solution?  It is not rocket science.  The dermatologist, surgeon, operating room personnel and anesthesologist all need to be employed by an accountable care organization (ACO)– that way there is just one predetermined fee for taking care of the whole patient for a year.  If the system does the work correctly they make some money, if they goof-it-up (as in this case) they lose money.   The incentive should be to do good and efficient work.  Not to make money by making mistakes.

This solution is extremely easy yet extremely unpopular with hospitals, surgeons, anesthesiologists, pathologists, radiologists, ophthalmologists and dermatologists.  The reasons are obvious — they make less money and must follow quality guidelines.  Given the low quality and extreme  high cost of US healthcare is that really a problem?  A few more articles by Ms. Rosenthal and a few thousand letters to congress might help.  Sadly, one industry lobbyist equals one journalist in this battle.


By the way, the lesion at the top is a benign seborrheic keratosis — harmless, but gladly removed by dermatologists ($250).

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Diagnostic Errors — symptom to treatment disconnect

DX Doc

Making a diagnosis is difficult.  And, doctors sometimes get it wrong.  “Wrong” is often harmless, usually expensive,  and sometimes deadly.

An article about incorrect diagnosis appeared this month in the British Medical Journal Quality and Safety which has been widely reported, including by the Wall Street Journal.  Dr. Tehrani and his co-authors  correlated health insurance claims (diagnosis) with malpractice suits.  They found “diagnostic errors appear to be the most common, most costly and most dangerous of medical mistakes.”

One might think the errors happen because the underlying problem is very rare.  On the contrary, the bulk of errors happen with common conditions.

Another article this month in JAMA Internal Medicine  by Dr. Singh and co-workers reported on common types of diagnostic errors — many of which were common in primary care:  (italics are blog examples)

  • Pneumonia
    • no chest x-ray for cough and high fever
  • Decompensated congestive heart failure
    • no BNpeptide checked
  • Acute renal failure
    • no check of basic metabolic panel for fatigue
  • Cancer
    • ignoring Mammogram findings or blood in sputum
  • Urinary tract infections
    • not checking urinalysis or treating soon enough

The flaw in the process that contributed to the wrong diagnosis included:

  • Inadequate patient encounter (too short or not focused on problem)
  • Not seeking referral when needed (like not getting a cardiology consult for chest pain)
  • Patient related factors (not returning for follow-up)
  • Not taking risk factors into account (like family history of colon cancer)
  • Losing track of test results (urinalysis report filed but not viewed)
  • Not getting the right test (not getting a chest x-ray for shortness of breath)

Problems at the time of patient encounter are a major contributor:

  • Poor history taking (provider did not listen or ask questions)
  • Inadequate examination (provider did not examine problem area — like a breast nodule)
  • Inadequate testing (not considering a colonoscopy for blood in the stool)

When a person has a health problem the whole idea is to connect the dots …problem…diagnosis…treatment.  If the diagnosis is not correct then good treatment is disconnected.

Providers often do not consider enough possible causes for abnormal findings.  Those possibilities are called the “differential diagnosis”.  There are books and several free sites on the Internet that provide such lists.  One such site is DiagnosisPro.  If you like other sites leave a comment please.  Some electronic record applications include a differential diagnosis automatically — nice feature which should always be installed.

So, what is the solution?  Most experts agree, the quality of the provider-patient interaction must improve.  Providers need to follow known guidelines plus use differential diagnosis aids.  Patients need to look out for themselves by using the Internet or books to  understand symptoms and test results.  The best solution is a stronger partnership between patients and providers.  See earlier posts in this blog about shared decision-making and patient centered care.

Can all errors be prevented?  NO.  To err is human.  The point is to minimize the errors, and there is obviously a lot of room for improvement.

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Malpractice — same problems over and over

What causes medical malpractice suits for health care providers and hospitals?  The simple answer is ERROR.  The most serious errors happen in hospitals but the most frequent errors happen in outpatient clinics.

James Reason (“Human error: models and management.” Bmj 320.7237 (2000): 768-770) is well known for his study of the causes of human error.   He breaks error into 3 main categories:

  1. Skill based error (not paying attention to the right things)
  2. Rule based error (not following the right rule or following an incorrect rule)
  3. Knowledge based error (not knowing or incorrectly concluding)

Health care providers make human errors all the time.   When the error actually causes injury the injured party will sometimes seek compensation through the legal system.

If humans “do the best they can” performing a task the error rate is about 10%.  For example, if a nurse is to administer a medication to a given patient there will be an error 1 out of 10 times.  Wrong patient, wrong medication, wrong dose, or wrong time just to name a few possibilities.  The goal in error reduction is an error rate in the 1 out of a million range.  Humans alone can not do that!  Prevention of errors absolutely requires systems — sometimes as simple as a checklist or sometimes as complex as a robot that packages medications with a barcode and later scanning of the code before drug administration to a patient.

Medical malpractice suits (excluding the presence of legal malpractice) arise out of a failure to have adequate systems to control error.  But, malpractice suits are only the tip of the error iceberg.  All interventions in health care must have active quality monitoring and error prevention systems.  Health care providers, to their patient’s detriment, yearn for simpler times — just the good old doctor-patient relationship in a small office with low overhead costs and no malpractice lawyers.  Without a focus on quality and standards the good old days were really the bad old days of medical care.

The cost of medical malpractice to the US healthcare system is estimated at $55 billion or 2.4% of the overall system cost.  However, the statistic misses the point.  How much is spent on preventing errors?  A wonderful trade-off would be to spend that much money to prevent errors in the first place rather than paying compensation for errors after they happen.  Lawyers say they see the same errors over and over.  One patient, one error, one trial then repeat with no intent to stop the cycle.  This is a major flaw in the US justice system.  Each settlement and each trial should result in some change to the system where the error happened.  The usual outcome is “it’s your fault”, “try harder” and “do the best you can” — which are clearly failed quality strategies.

Prevention of errors is a costly endeavor (although well worth the cost).  The following are examples of systems to reduce errors:

  • Electronic medical records
  • Electronic prescribing (computer checks for mistakes)
  • Checklists for surgeons
  • A strong quality management program both inpatient and outpatient
  • Standardized orders in the hospital
  • Standardized protocols for outpatient treatment
  • Mandatory involvement of health care providers in quality improvement
  • Development of a culture of safety for health care providers
  • Formalized hand-off when changing shifts or going off call
  • Barcoded medication administration
  • Robotic packaging of medications
  • Hourly nurse rounding to prevent falls
  • Include the patient in the effort to improve safety


The above list is seriously incomplete.  Health care is complex and changing.  The systems to prevent error need to be adapted to the circumstances and to our changing understanding of treatment.

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