How To Get Better At Harming People Less

Paul Levy

Posted 4/09/12 on Not Running a Hospital

Every day, a 727 jetliner crashes and kills all the people on board.  Not really.  But every day in America, the same number of people in American hospitals lose their lives because of preventable errors.  They don’t die from their disease.  They are killed because of hospital acquired infections, medication errors, procedural errors, or other problems that reflect the poor design of how work is done and care is delivered.

Imagine what we as a society would do if three 727s crashed three days in a row.  We would shut down the airports and totally revamp our way of delivering passengers.   But, the 100,000 people a year killed in hospitals are essentially ignored, and hospitals remain one of the major public health hazards in our country.

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Reverse the Expectation of Punishment

Paul Levy

Posted 2/21/12 on Not Running a Hospital

An article in amednews.com reports:

[D]ata released in February by the Agency for Healthcare Research and Quality show that most physicians, nurses, pharmacists and other health professionals working in hospitals believe their organizations are still more interested in punishing missteps and enforcing hierarchy than in encouraging open communication and using adverse-event reports to learn what’s gone wrong.

These findings underlie the tragedy in medicine that results in thousands of preventable hospitals deaths each year and untold harm to other patients. Correcting this problem is a matter of leadership, plain and simple.  The clinical and administrative leaders of hospitals need to set a different standard.

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Tracking Adverse Events

Paul Levy

Posted 1/08/12 on Not Running a Hospital

recent report from the Office of Inspector General at the US Department of Health and Human Services finds, unsurprisingly, that hospital incident reporting systems do not capture most patient harm.  A summary of major points:

All 189 sampled hospitals had incident reporting systems to capture events, and administrators we interviewed rely heavily on these systems to identify problems.

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Labor, Delivery, Disclosure, Malpractice

Paul Levy

First posted 9/4/11 on Not Running A Hospital

Let’s talk about a different kind of labor on Labor Day weekend, the kind that delivers babies, and an order issued this past week by the U.S. Court of Appeals for the Seventh Circuit in Chicago.  The case is styled Arroyo vs United States, and I want to focus on the concurring decision by Judge Richard Posner.

The appeal involved a question of whether a malpractice lawsuit was filed by the Arroyos after the statute of limitations had run out.  The statute exists to prevent “stale” lawsuits, those filed years after a reasonable period of time.  It makes sense to have such a statute of limitations, in that defending a case gets progressively difficult as years go by:  Memories fade and potential witnesses become unavailable.

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Let’s Just Keep Killing and Maiming Them

Paul Levy

First published 5/9/11 on [Not] Running a Hospital

Old patterns die hard. Back in March 2010, I posted a chart from the ACHE that Jim Conway had sent me showing a decrease in the ranking of quality and safety among priorities reported by hospital executives.

Now comes an article in Health, Medical, and Science Updates about a study by the Beryl Institute, entitled “The State of Patient Experience in American Hospitals.” Of those places surveyed, 51% were individual hospitals and 49% were hospital groups or systems. There was an even mix of urban, suburban, and rural facilities.
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2 Kidneys vs. 100,000 Lives

PAUL LEVY

First published on [Not] Running a Hospital

This story about a kidney transplant mix-up in California is bound to get lots of coverage. It is these extraordinary cases that get public attention. I am sure it will lead to a whole new set of national rules designed to keep such a thing from happening.

Of course, such rules already exist, and it was likely a lapse in them that led to this result.

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Defining A Defect

PAUL LEVY

Originally published on [Not] Running A Hospital

From Charles Kenney’s book Transforming Health Care, about Virginia Mason Medical Center’s journey:

Implementing the program was not a simple matter. Defining a defect in a medical setting presented a challenge…. [D]octors pushed back. The argued that many instances of harm — ventilator-acquired pneumonia, for example — should not be considered an error because these things happened in medicine. Complications, they argued, were inevitable.

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No Outrage, No Story In Dead Patients

MICHAEL MILLENSON

Originally published on 12/22/10 on Kaiser Health News

A good story involves drama and conflict. A federal judge with Republican ties nixing a Democratic president’s signature achievement in ensuring access to care for all is a great story. One, two, even three reports about hospitals avoidably (if inadvertently) killing tens of thousands of Americans annually once they have the insurance that ensures them access to care apparently has little, if any, drama at all.

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Would You Want This Surgeon To Operate On You?

DOV MICHAELI

Originally published 10/20/2010 on The Doctor Weighs In.

Did you ever think that when you check into the hospital for surgery you may end up missing a perfectly good kidney and your bum kidney still in place? If it wasn’t so serious it could have been the opening line of a Joke (“there was this guy who checked into the hospital…” Please send in your contributions). A paper published recently in the Archives of Surgery is nothing if not alarming. In brief, the researchers examined the insurance records of 27,370 physicians in Colorado who reported adverse occurrences over a period of 6.5 years. Highlights of their findings:

  • They operated on the right site but the wrong patient at least 25 times.
  • Right patient, wrong site: 107 patients.
  • The wrong-site wrong-patient occurrences made up 0.5% of all medical mistakes analyzed in the study
  • The authors estimate that the actual number is much higher; this is the tip of the iceberg.

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Why We Still Kill Patients: Invisibility, Inertia, And Income

MICHAEL MILLENSON

Originally Published 12/6/10 on the Health Affairs Blog here.

DESCRIPTIONA recent front-page article [1] in the New York Times conveyed grim news about patient safety. The first large-scale study [2] of hospital safety in a decade concluded that care has not gotten significantly safer since the Institute of Medicine’s 1999 estimate [3] of up to 98,000 preventable deaths and 1 million preventable injuries annually.

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