Comments

Tom,

I'm sure most people would be surprised to know how much fatigue plays a role in errors on the part of other hospital staff, also.

I ran the E.R. 12 hours on/12 off, for 7 nights on/7 nights off for a nearly two year stretch. Add in driving time to and from work (was about 30 miles each way), trying to tend to personal life and business during the daytime/off hours (worked 7p-7a shift), and the more than occasional incidence of having to stick around beyond my scheduled off-time because of patient load or being in the middle of a serious case, and there is no expressing the amount of physical and mental fatigue I experienced.

I wouldn't recommend it. It does create a dangerous situation. A lot of hospitals have moved away from 12 hour shifts to 8's because of it, but many still schedule that way.

It's not just the doctors. And since the Balanced Budged Act of 1997, staffing cuts added more workload to the remaining team members, leading to many of the more experienced ones burning out and leaving the field altogether.

Another of those vicious cycles.

I agree that unnecessary patient deaths and injuries in hospitals is tragic, unacceptable, and under-recognized. It can be reduced significantly if not nearly eradicated, but not without some open, honest dialog about the problem and some serious work on fixing it.

Posted by Dan Gunter at May 15, 2009 12:31 PM

Tom:

Thanks for sharing this - it is very scary and also disturbing to read the transcripts of the Buffalo flight crew prior to crash.

I was driving in my car the other day listening to my local NPR station and they reported in the news that a particular hospital in the area was cutting its nursing staff by a certain percentage. In any case, the hospital's spokesperson said, very confidently, that these cuts would not effect patient care. My first thought: "yeah right."

Tom, great work as always!

Posted by Tim at May 15, 2009 12:55 PM

Tim,

Wanna bet if the financial picture for that same hospital changed and they decided to hire, for example, 50% more nurses they'd be singing the "This will improve the quality of patient care tremendously!" song?

Lies. Hypocrisy. "Sweep it under the rug" tactics. It ALWAYS affects patient care when you lose staff (unless, of course, something else is going on and they've already lost proportionate patient load.) Either way, they HAVE a PROBLEM. Several problems, most likely.

#1 is denial.

Posted by Dan Gunter at May 15, 2009 1:06 PM

Tim - if ‘cutting its nursing staff by a certain percentage’ doesn’t affect patient care in that hospital my question would be; What the hell are the nurses doing? I am with Dan 100% - of course it will affect patient care. Let's be clear these ‘hospital spokespersons’ are usually folks employed in the warm office of the communications department who know how to put a positive spin on bad news. (I speak from personal experience) They speak from the comfort of corporate headquarters and not from the hospital ward where we find the patients. I would rather the media ask the nurses doing the work at the front line if we really want to get an accurate picture.

Posted by Trevor Gay at May 15, 2009 3:01 PM

Trevor and Tim,

Definitely... ask the nurses. And the patients. And the nursing assistants. And the doctors. They'll all tell you that it affects patient care, because cutting nursing staff affects every one of them, directly and indirectly.

Last thing you can expect a hospital P.R. person to do is tell you that something they are doing is going to NEGATIVELY impact the quality of patient care. Probably afraid they'd get subpoenaed into court to testify in the inevitable malpractice cases if they did. Not a "plus" for their career longevity, even though it would be the right thing to do. Honesty... imagine what that would be like to hear?

Posted by Dan Gunter at May 15, 2009 3:13 PM

P.S.: on the other hand, follow that same P.R. person around if they're involved in "lobbying" for the hospital's reimbursements, tax funds, etc., and I'll bet you'll hear them telling the exact opposite story. "We need more nurses SO BADLY... patients are suffering from understaffing..." The story changes to please the intended audience.

"A double minded man is unstable in all his way." James 1:8 (I think - humbly will accept correction if that's incorrect.)

Posted by Dan Gunter at May 15, 2009 3:28 PM

30,000+ die of flu in the USA each year - 45,000 die in car "accidents". The latter is down due to the recession.

"Sickcare" consumerism is what the devious culture has us conditioned for in too many countries. Line us up for meds & surgery & psychiatric aid - starting as kids.

Live long & healthful/wealthful/happy - that is the best revenge. Awhile back we started the Love/live clean & serene scene (LLCSS)- whereby everything we ingest from cosmetics to shower water to chapstick to shampoo to lotion to soap to clothes lint to sunglass frames to drinking water to nutrition/vitamins to where we reside, et al is the purest possible.

Everything that touches/gets into the body must be the purest. Sorry Diet Coke/Pepsi Max aspartame/splenda fans! Have we gone insane since we stay cold & flu & sickday free? Do we still sneak in a wellness day or 2/3 - of course.

TP - thanks - he/she that gets the best REM sleep wins - survival of the freshest >:)

Posted by C Love at May 15, 2009 4:57 PM

Why are you loath to admit watching any TV programme? What's so wrong with it being, "...fundamentally a soap opera"? And if it's inspired an interesting question, shouldn't it be feted instead of demeaned?

Posted by Mark JF at May 15, 2009 5:00 PM

PS - never have surgery in a university teaching hospital - once you are out cold some sniveling exhausted "med" student may sneak in a few scalpel slices! :>)

Posted by C Love at May 15, 2009 5:56 PM

"(In fact, to some significant extent, 'perky' beats raw talent.)"

This is so very nice. The former requires alertness the latter not necessarily so.

Thanks for the post, TP, as always.

Posted by Judith Ellis at May 15, 2009 6:24 PM

Yes, Tom, I share your concern. I've been studying thoroughly advanced risk management concerning airliners and their mishaps. Besides all what you state, I have this overbearing feeling that from the aircraft to the airport and passenger we need an extreme makeover. GE and Rolls Royce make turbine engines that can endure through four tons of "ice" (so they say). But then we see the bird sending a "magnificent" plane onto the Hudson. I'm happy for the life saved and saddened for the industry damage.

1.We don't need fuselage anymore as per Century-21 standards.
2. The turbine and their disposition are going to have exuberant different, perhaps not 2 engines but 4 or 5, operating without (a) A1 (petroleum), (b) Ethanol. Urgent re-engineering is required in extremis.
3. The engine disposition as per the airplane is going to have to be different.

IN ADDITION, as with teachers, police people, professors, PILOTS MUST BE PAID AND TRAINED AND POLICE VERY HARD.

I have worked with a former high-ranked NTFS director and investigator since 1964 in "Risk Management Forensics for Civil Aviation." No way "Joey," like this I will not fly commercial at all.

Posted by Andres Agostini (Andy) at May 16, 2009 12:16 AM

PS - never have surgery in a university teaching hospital - once you are out cold some sniveling exhausted "med" student may sneak in a few scalpel slices! :>)

NEVER ON A HOLIDAY
NEVER IN JULY OR AUGUST
NEVER ON A SUNDAY

Posted by tom peters at May 16, 2009 4:39 AM

Interesting post Tom, I agree with the correlation. When my wife was Resident Physician I would often go pick her up at work and get the car later, cause I didn't want her driving home after spending 36 hours in the hospital. I think they changed the resident rules a couple of years ago, but they still spend long hours.. She tells a story of a heading to the elevator and seeing a general surgery resident asleep standing up in the hallway.

Posted by Douglas Sandquist at May 16, 2009 11:07 AM

When I worked with a computer dealership (IBM, Compaq, AT&T) we found out how to identify on the IBM machines what day of the week it was built on. We literally picked out the machines built on Mondays and Fridays and did not sell those to our most valued customers. You may think I'm joking, but we had more "out of box failures" with those machines than the ones built Tuesday-Thursday.

Same factory. Same parts. Same methods. More problems. Only variable we could identify was "human errors." Anecdotal? Maybe. But sometimes you dig around and just figure things out. Just because you don't have "hard data" with the blessings of an engineer and mathematician signing-off on a $100,000 study doesn't necessarily mean you're wrong.

Same holds true in medicine: it doesn't take a genius or a lot of time to make the common sense connection that fatigue and increased workloads WILL lead to more errors.

"Oops. Another patient just died. Have the CQI director add a check mark in the 'adverse outcome' column." NOT GOOD ENOUGH. Yes, by all means track and study results, but not at the expense of actually DOING something. We need to make SWEEPING changes in dealing with the problems of fatigue and workloads in a lot of fields and do it NOW. Not when we think we have enough evidence to say incontrovertibly that something is wrong. We know it already. So...????

Posted by Dan Gunter at May 16, 2009 11:48 AM

Although obviously pilots and doctors need to be fresh and on top form when they operate. I also wonder how many dumb general business decisions have been made in a fit of tired emotion.

More than once have I deferred a difficult conversation to another day because I wanted a calm fresh head.

One of the areas you see problems the most is a new parent - I am often shocked how badly new parents are sometimes treated by their employees. Surviving on less than a couple of hours of sleep a night would raise eyebrows in a torture enquiry and yet in business somehow people are expected to "cope".

As in all things self awareness is paramount.

Posted by PaulH at May 17, 2009 7:21 AM

Insightful comments here that I appreciate. And poor quality sleep can be like having a .10 blood alcohol content per some studies. So as a sleepy driver one can become a menace to society.

Most driving errors are intoxication (alcohol, prescriptions, recreational drugs) related & lack of sleep must be right there too.

I call it the 'Trevor effect' bouncing from wine/whine to Pepsi Max & back again over & over ... :>) ... insidious & yet "brilliant"!

PS - why is it when I feel sleepy I CRAVE operating heavy equipment - like a giant loader perhaps on a logging landing? :>)

Posted by C Love at May 17, 2009 5:26 PM

Suggest a read of 'Managing the Risks of Organizational Accidents' by James Reason. Talks of the 'latent conditions' and organisational problems associated with accidents rather than the human side.

Although it was written with heavy industry / aviation in mind, I only now see the connect with medical.

The scenarios he uses are eerily similar to some of your previous posts. For example, poor handover of work from shift to shift leading to disasters on planes.

Posted by Peter at May 17, 2009 11:22 PM

As a former pro pilot I would completely agree with the need for being well rested but there is another nagging issue in analyzing the pilots' reactions that lead to Buffalo incident.

Regardless of not having been well rested the captain's reaction to pull back on the stick, thus bringing the aircraft attitude to a more nose up position, is completely counter to all training starting with your second or third hour of flight time as a beginning student. In an unrested state he should have been even more inclined to have reacted in the way he was trained as cognitive process is reduced my the tired condition of the brain.

To me this accident is indicative of a number of issues, lack of rest right up there, but more importantly a lack of ongoing training to prevent a stall condition on approach which has traditionally been a high ranking cause of aircraft incidents leading to fatal crashes.

Posted by Mike Shafer at May 18, 2009 7:45 AM

C - Thanks for the compliment as always - Diet Pepsi of course :-)

Posted by Trevor Gay at May 18, 2009 12:35 PM

I see an American Airlines pilot has just failed a breathalyzer test. Can we have fresh AND sober?

Posted by RobCH at May 21, 2009 12:42 PM

I can just hear it now... excuse to an FAA officer: "I was only weaving to heat up the tires."

Posted by Dan Gunter at May 21, 2009 12:51 PM

I found myself wondering the exact same thing the other day. When I'm really tired, I can barely function at my job... and I'm just a writer. No one's life is at stake.

It boggles my mind that hospitals would deliberately make doctors work insane shifts. I can't see how it helps the patients when doctors are exhausted. It's dangerous, and I'm sure people get hurt all the time from it.

Why do doctors work such long shifts anyways? Because the hospital is trying to save money by paying less people, or is it some insane rite of passage that new doctors go through because the old ones had to?

Posted by Katie at May 28, 2009 12:06 AM

Katie, the problem stems largely from two issues.

The first is an outdated "continuity of care" model. The (very worn out) theory is that the same doctor should see to as much of a patient's care as possible. The fear (with some legitimate roots) was that each time a different doctor steps in, taking on the responsibility of taking care of a patient on the heels of another doctor, there is a chance of something getting overlooked or an ongoing treatment plan veering off course. Communications is the key element in preventing this. Lack of thorough notes in the patient's chart, illegible handwriting, delays in dictated notes getting transcribed and placed in the patient's chart -- these things did increase the risk of errors and omissions. But with more modern, electronic medical records, much of this can be eliminated -- provided hospitals actually implement it and get the doctors up to speed on utilizing it.

The second issue is one of reimbursements. Doctors get paid per patient visit, per procedure performed, etc. Thus many of them perform surgeries first thing in the morning ($$$), make rounds to see their patients in the hospital ($$$), then go back to their offices to see patients there ($$$). Although it sounds like they should be making a ton of money for this, insurance companies have tightened the screws somewhat on how much they actually pay the doctors. Additionally, the Health Care Finance Administration (HCFA), et al, have cut most of the reimbursements for patients on Medicare and state "Medicaid" or similar programs have also lowered many of the reimbursements. With the exception of some highly specialized doctors performing high-reimbursement procedures, doctors now have to see more patients and do more procedures just to generate the same amount of revenue as a few years ago. When you factor in the large overhead of operating a practice (fixed costs, utilities, staff wages and benefits, malpractice insurance premiums), and a ton of other costs, doctors do not really come out making as much money on average as most people would imagine.

I actually had a doctor share his income tax records with me for a couple of years. He had been a nurse before getting his M.D. His claim (which I found hard to believe) was that a well paid nurse can actually make as much money -- allowing for cost and lifestyle differences -- as a doctor can. I found that very difficult to fathom. Then he showed me his tax returns. After expenses (including the cost of his home and Mercedes, which he admitted are the kinds of things too many doctors think they are "expected" to have) I actually HAD more money left over than him in one of those two years, and the other year was a very close tie (less than $2,000 difference). He had grossed over $800,000 in his practice the year that I had more disposable income than he did.

It really isn't the hospitals that put doctors in these situations, nor is it just the doctors themselves -- it results from many factors; however, the hospitals and the doctors themselves DID play A role in it and both will have to play a key role in finding ways to change it.

Health care is largely a "numbers-based" industry from the perspective of those who control the purse strings. If doctors and hospitals can produce equal (preferably BETTER, but at least equal) levels of quality in terms of outcomes, measured in such terms as average length of stay, complications, death and comorbidity rates, cost of care, etc., while presenting better models for providing care, HCFA and others will see the benefits and go along, supporting it by actually paying for it. But they refuse to pay more (or even as much as before in many situations) just to keep getting the same results.

It's a very complex system with lots of participants and factors. Sadly, when it's all said and done, it ends up being more about money than patient well-being. No margin = no mission.

But that has to change. The health care industry has an acute need for people like Tom Peters, Leland Kaiser, and others to fight on the front of real quality from a patient's perspective. And as much as I hate "politics," it's a very, very real factor in the equation, as we need people lobbying for a combination of investments in better models of care while at least keeping hospitals in business while they work on it.

The hospitals must be doing their part, too, by actually finding ways to achieve the increases in quality of care. There is WAY TOO MUCH FINGER POINTING in the health care industry.

Rare but beautiful is the health care team that says "WE are all in this together and WE must find a better way." The more commonly heard words go something like "YOU have got to shape up or you're going to put US out of business."

Whenever I hear someone using the "What YOU are doing to US" type of terminology without recognizing and addressing the "WE" aspect, my stomach turns.

Posted by Dan Gunter at May 28, 2009 8:00 AM