Comments

I recently had surgery at a local hospital, a medium-sized facility in a medium-sized city. While I have no complaints about the quality of the medical care I received (both doctors and nurses were capable, efficient, and conscientious), I noted that the hospital dropped the ball on communications a couple of times.

For example, I was supposed to undergo a procedure that required a CAT scan, but the instructions to prep me for the scan hadn't percolated down to the nursing staff; so I was shunted into the operating room, only to be spit right out again when they tried to do the scan and discovered that it wasn't working. (So I had to wait 24 more hours, in pain, for a slot in the operating room.) On a lesser note, I was on a "clear fluids" diet at first, but after that procedure was completed my doctor said I could resume eating normal food -- but nobody told the nurses or the food service, so I had 12 more hours of popsicles and broth before word got out.

Likewise, I was shocked at how much the hospital relied on paper. When I was first admitted for surgery, I signed an information release so that friends and family members could call in for news on my condition. I had the surgery, went home, began to have (not unforeseen) complications a few days later, and ended up in the emergency room. The hospital claimed that I didn't sign another information release when I was readmitted (I think I did, but they lost it). So nobody could get any information unless they actually walked in and talked to me -- which, as I was heavily sedated, wasn't much help. The upshot was that my sister became concerned and flew halfway across the country to find out what was going on!

Why rely on a piece of paper that can easily get lost, especially in a chaotic place like the ER? Why assume that "someone" will communicate the doctors' instructions to the nurses, when the whole transaction could be easily handled electronically? And what if the miscommunication had been about a potentially life-threatening situation?

Posted by Paula at September 12, 2006 5:43 PM

It is SICKENING that 85% of healthcare information is still paper-based when there is unequivocal evidence that good electronic records save lives. Thanks for the kinds words about VA healthcare, where I am proud to work.

Posted by David Bachman at September 12, 2006 6:40 PM

In the UK we're having a discussion about patient deaths due to consultant error.

The long term defensive practice of covering up errors has led to failure of accountability. The power relationship is similar to many political systems.

There's a call for communications and team working training for NHS Consultants.

This weekend on a trip to Bath Spa I overheard a group of nurses talking about hygiene. (We have MRSA issues in many hospitals.) They were saying that it's the fault of doctors who don't wash their hands between patient examinations.

Didn't sound as if they were willing to risk disfavour by reporting the danger. Hence this comment and my blogs.

Posted by Jana Fielding at September 13, 2006 7:43 AM

"Point-of-Care Testing" - 1999 Christopher Price, PhD, FRCPath -Jocelyn M.Hicks PhD, FRCPath - The technology, work process mapping, patient and physician benefits of testing at bedside with immediate dissemination of the medical records to the right people has existed for awhile. It is as usual, the economic and bureacratic status-quo that has kept progress and innovation at bay.

Posted by Tom at Proteus at September 13, 2006 8:55 AM

Tom, one of my clients is a small high-tech company serving health care's EMR needs. They aren't alone. There are lots of entrepreneurs eager to make the health care system safer.

Posted by Lewis Green at September 13, 2006 12:58 PM

I'll try to add to this discussion again, sans the URLs.

Medicine has a family of serious problems that anyone addressing the above problems also needs to be aware of. An intergrated, systematic approach to the entire set of problems is required because the root is at the physician-patient interface. These additional problems include a significant proportion of current practices not being supported by sound scientific evidence, the slow dissemination of critical research findings to practitioners, and the need for efficient, effective procedures to translate and synthesize the huge and expanding body of knowledge into a form that is readily accessible in real time at the point of need, which again is the clinician-patient interface. To address these problems, the paradigm of "evidence-based medicine" has evolved over the last decade.

Google ""what proportion of healthcare is evidence-based?"

Resource Guide (Andrew Booth):
• Summary of 18 studies, executed between 1995 and 2000, to determine the strength of evidence supporting clinical procedures on patients
• Of 128 clinical procedures per study (range of 40 to 1,990
procedures per study, unweighted median values)
- 38% were supported by RBCT Type I (strongest) evidence
- 22% were not supported by convincing experimental or nonexperimental
evidence

For a general discussion of many of the problems, Google "What Is Evidence-Based Medicine and Why Should It Be Practiced?" and look for the on-line version of the paper. Figure 1 summarizes a lot of the problems, particularly with respect to the diffusion and uptake of critical new information.

To see one major component of solving these problems, Google "Cochrane Collaboration".

Posted by JMG at September 14, 2006 8:45 AM

I forgot to include the following (answering the question - is all this EBM stuff really important?):

Autopsy evidence of Physician Diagnostic Error Rates

Changes in rates of autopsy-detected diagnostic errors over time: A systematic review JAMA 289(21):2849-2856 (2003)
• 53 autopsy series published 1966 - 2002
• 24% major error rate (4.1% - 49.8%)(Involved 1o cause of death but did not affect outcome)
• 9% class I error rate (0% - 20.7%) (Likely resulted in the death!)
• Accounting for steady improvements, current major error rate is likely 8%- 24% and class I rate is likely 4%-7%
• This means that of 850,00 individuals dying in US hospitals each year, 34,850 would have survived to discharge if misdiagnoses had not occurred!

Does the practice of medicien have serious problems? You betcha!

Posted by JMG at September 14, 2006 8:52 AM

I'll get this right (eventually). The paper title from above, which is available on-line, is:

Montori VM GH Guyatt. Respir Care 46(11):1201-1211 (2001)

A paper, available on-line (I think everywhere), on the Cochrane Collaboration is:

viagra brand online Knowledge for Knowledge Translation: The Role of the Cochrane Collaboration
J Contin Educ Health Prof 26(1):55-62 (2006)

The practice of medicine is a tough decision-making process involving a large amount of uncertainty - humans are very complex biological systems with a high degree of individual variability about which much is not known and the signals these systems emit are very subtle and deceptive. Attempting to reduce cognitive errors by forcing physicians into EBM alone is not the answer. Somebody has to figure out how to support their decision-making in the face of uncertainty by meeting their information needs very efficiently (very short search times) and very effectively (very concise, high quality information results most every time) at their point of need in a transparent, real time mode.

Posted by JMG at September 14, 2006 11:38 AM

Re: error rates

More detail on the Class I errors would be really helpful: did the doctor making the diagnosis err because of (1) not enough patient information or (2) bad or misleading information (both of which can be improved with better information systems); or was it because of the doctor's (3) making erroneous assumptions, (4) interpreting an ambiguous situation the wrong way, or (5)stupidity/arrogance/ignorance -- which all the good information in the world won't help!

Posted by Paula at September 14, 2006 2:40 PM

IndyStar.com Metro & State

9:16 AM September 20, 2006

Third preemie dies from overdose
Related articles
• Methodist may speed up safety updates
• Methodist offers to pay restitution

Star report
A third premature infant who was accidentally given an adult dose of a blood-thinning drug at Methodist Hospital has died, hospital officials said this morning.



Thursday Dawn Jeffers, 5 days, died at 11:38 p.m. Tuesday in Riley Hospital for Children, where the girl had been transferred after the overdoses were discovered late Saturday and Sunday.
In all, six premature infants in the Methodist neonatal intensive care unit received the wrong dosage of heparin last week. Two others also died and three are expected to survive. The three are in critical condition because of their prematurity.

D'myia Alexander Nelson, 5 days, and Emmery Miller, 2 days, died at Methodist.

Methodist Hospital officials have called the overdoses an institutional failure and outlined a series of steps and training to prevent a recurrence.

Nurses administered the drug, which a pharmacy technician had placed in a medicine cabinet.

"We have already implemented measures to ensure that this incident cannot occur again, and we are continuing to take additional steps to enhance safety and quality at our hospitals," hospital spokesman Jon Mills said in a statement this morning.

"While nothing we can say or do can replace the loss this family, and the other families have experienced, we will continue to offer all of the support and assistance that we can."

The hospital will no longer keep certain doses of heparin in inventory, and all newborn and pediatric critical care units will require a minimum of two nurses to validate any dose of heparin.

The hospital has offered restitution to the families of the infants. Two of the families have retained lawyers.

“Their thoughts and their prayers are that they do not want this to happen again in the future,” said Indianapolis attorney Nathaniel Lee, who is representing the family of Emmery Miller.

This story will be updated.

Copyright 2006 IndyStar.com. All rights reserved

This information is from the Indianapolis Star newspaper.

Posted by Gary at September 20, 2006 1:55 PM