Alarm Fatigue Revisted

Originally posted 2-21-2011:
Back in August, I wrote about the problem of Alarm Fatigue in healthcare. Alarm Fatigue occurs when care givers hear medical device alarms so often, they develop a "cry wolf" reaction and start to unknowingly ignore those alarms.  The Boston Globe recently published an interesting special report about the issue. 

The article discusses a couple of specific cases in which alarms were ignored before a patient death. The article also highlights a number of studies showing how often alarms are ignored or just completely missed by hospital staff.  This is a specific item from the article I want to highlight:

"“We are at the point where we all know [alarm fatigue] is a problem,’’ [Dr. Brian Lewis, a cardiologist and medical officer in the FDA’s division of cardiovascular devices] said. “We know we’d like these devices to serve the public health better. But we need specific direction from providers on how these devices should be changed.’’

From reading this, I think this is a real opportunity for both hospitals and device manufacturers to work closely together to solve a real patient safety issue. Device manufacturers will tend to design alarms to be overly sensitive because “Missing a real event is much more costly to the manufacturer.’’  I think the algorithms and designs behind these alarms should be looked at a little closer to see if they can find a safe balance to keep alarms from being over sensitive. I said in my previous post that "device manufacturers should continue to study and understand user tasks and workflows to help evaluate which alarms are necessary." This is the basis of User Centered Design, which is a key philosophy that I believe helps lead to safer healthcare technology products. In this case, I think it will help avoid those situations where the alarm silence button on a device is blindly pushed or alarms get missed in the rest of the noise.  It will not solve the problem completely, but it would be a big step toward helping the alarm fatigue issue.

Wash those hands...or else!

Originally posted 2-6-2011:
It's Super Bowl Sunday.  That means today is a big day for Packer and Steeler fans, or a fun day for commercial lovers.  Regardless, it provides an excuse to have a party.  Wings, pizza, chips and dip, cut up veggies...many of us will be eating all kinds of finger food goodies. But before you started digging in, did you remember to wash your hands?

This seems to be a common question being asked of clinicians these days. Hand hygiene, or a lack thereof, is considered one of the major contributors to the spreading of infections among patients in the hospital.  As a result, many different hospitals are coming up with different plans to improve hand hygiene compliance.

I came across two blogs this last week that described two very different ways to address the problem.  This blog from the ECRI Instititue site describes a series of hospitals in Ohio that achieved 95% compliance with education, staff monitoring, and the installation of additional hand sanitizer dispensers.  It sounds like the success stemmed from savvy systems improvements to ensure clinicians maintained compliance.  A different approach was described in this Controversies in Hospital Infection Prevention blog.  It appears that the University of Pittsburgh Medical Center is considering fining employees for not following hand hygiene compliance in response to an increase of infections. 

There definitely appears to be a "carrot" and a "stick" feel to these approaches.  I'll be curious to see if things improve at UPMC if the fines are levied.  This sort of punishment goes against a systems level solution where improvements are made to conditions around the clinician to make sure no harm reaches the patient. I have heard the argument that a fine system like this would be a wake up call to improve compliance.  I'm not sure I'm convinced.

What are your thoughts on this?  Is the threat of a fine an effective way to get you to wash your hands?

ECRI Institute's 2011 Top Ten Health Technology Hazards

Originally posted 1-27-2011:
Most people have a New Year's resolution or two at this time of year.  As we near the end of January, I'm guessing some of the resolutions have already been broken. 

With the theme of making improvements for 2011, I wanted to share a list that shouldn't be ignored past the month of January: The ECRI Institute's Top Ten Health Technology Hazards list for 2011.  The list highlights technology that can potential cause the most harm to patients when not implemented or working properly. It provides a nice starting point for hospitals that are looking for areas to be proactive in their Patient Safety efforts. 

This year's Top Ten list:

1. Radiation Overdose and Other Dose Errors during Radiation Therapy
2. Alarm Hazards
3. Cross Contamination from Flexible Endoscopes
4. High Radiation Dose from CT Scanners
5. Data Loss, System Incompatibilities, and Other IT Complications
6. Luer Misconnections
7. Oversedation during use of PCA Infusion Pumps
8. Needlesticks and Other Sharps Injuries
9. Surgical Fires
10. Defibrillators Failures in Emergency Resuscitation Attempts

The nice thing about the list is that it provides a little background behind each hazard.  It goes on to provide tips around how to address each of the hazards to protect patients from harm.  The advice given is coming a system level view around the technology, as they make suggestions like having a protocol around alarm-system settings, providing proper staff training for equipment, and having a clinician double check PCA pump programming. The list is not comprehensive, but provides a nice high level overview of potential technology hazards and how a hospital can build the system around the technology to stop any potential harm from reaching the patient. The best part is, the list is free.  The link above will take you to the page to sign up for the list.

Here's to a safer 2011!

Scribes - a benefit or detriment to Patient Safety?

Originally posted 1-12-2011:
I recently watched an interesting BBC news item on TV about Medical Scribes.  According to the piece, the hospital was hiring medical students to do rounds with attending physicians.  The students would be in charge of documenting the notes and actions of the physician, allowing the attending to spend more time interacting with the patient.  It essentially split the physicians role into two: the caretaker that assessed the patient and made the clinical decision and the documenter of that information.  After a little searching, I found a brief description of this online. It appears the problem for physicians was the amount of time it took to document everything into the Electronic Medical Record was taking away time from interacting with the patient. 

While watching the news piece, some of my friends and I got into a discussion on whether or not this was a good idea.  The most obvious benefit is allowing the physician to take more time to focus on the patient, assess their situation, and be able to make better clinical decisions for treatment.  These are primary tasks for doctors, so it would seem the Medical Scribes would be a positive addition to the Heathcare system.  However, the addition of the Scribe can add another potential place for handoff errors.  Are there situations where the Scribe documents the wrong information or misinterprets the situation at hand?  I wondered if the physician took the time to review the notes to give the final stamp of approval to what was documented. This didn't seem clear to me while watching the TV piece, but the linked article does say, "Later, doctors check for accuracy, make any additions or corrections and sign off."  How much later though?  Right away or at the end of their shift? 

In my opinion, I do think this brings more good than bad.  I believe allowing the physicians to focus on the patient will lead to better, safer decisions and an all around better patient experience.   Like any change or addition to the Healthcare system, it is important to make sure it is implemented well to protect the patient from error.  If implemented with timely reviews and sign offs, then these sorts of handoff issues should be caught and not reach the patient.  One other thought I had from reading the linked article is whether or not the addition of Scribes is a band-aid for hard to use Healthcare software.  It's hard to say, because physicians have a high work load. But I know the consequences of poorly design software can definitely add to that work load.  I have to think this may be a nice workaround to allow the physicians to focus on who is important - the patient.

Getting Closer to Safety Standardization for HIT?

Originally posted 12-23-2010:
As the use of Electronic Health Records (EHRs) continue to grow in healthcare, more questions are getting asked around the safety of such systems. Despite the innovation and efficiencies they bring, there are also potentially dangerous side effects to bringing the technology into the healthcare environment.  I've written about how the lack of standardization and poor software design are some of the culprits that leave a patient safety hole in the health system.  It goes without saying that I was pleased to see the Institute of Medicine has created the Committee on Patient Safety and Health Information Technology.

According to this New York Times article, the committee has been tasked with a year long study of such safety concerns with Healthcare Information Technology (HIT).  I am really glad to see that there is some serious action being taken to look closer at this.  The article pointed out the FDA has seen 260 reports of HIT malfunctions that had the potential to create harm. Since reporting HIT issues (which are not currently considered medical devices) is voluntary, I agree with Dr. Shuren that this may be "the tip of the iceberg." I also liked Dr. David's Blumenthal's quote on this: "At the same time, any time you change the world you create risks. We want to make sure that implementation is as safe as it can be and all safety benefits are realized.” 

I hope the committee takes a careful look at this and identifies the biggest HIT safety concerns. Hopefully they propose potential solutions around these concerns and deliver a smart list of recommendations for HIT systems.  For years, there have standards on medical devices to ensure their safety to the patient.  HIT systems provide data that directly impacts decision making for care givers, which does impact the quality of care a patient receives.  

I know there are concerns about government HIT regulations. Carl Dvorak's quote summarizes the concerns of the HIT vendors well: "The policing of design by a third party or agency, however well intended, will likely stifle innovation and inhibit the growth and development of electronic health records in the future."  I understand this concern, as I have seen how the FDA and other government mandated medical error reporting systems can slow things down and be a bear to work with.  That's why I said a "smart list" should be delivered.  I think it is possible to develop standardization that promotes safety, yet is viable for the manufacturers.  Medical device manufacturers are still delivering innovative products, so it is no impossible for this to happen in the HIT world. Regardless, safety should be a priority and shouldn't be sacrificed in HIT development.

This should make 2011 a little more interesting for world of Patient Safety. Have a wonderful holiday!

Error Disclosure and Building Trust

Originally posted 12-6-2010:
I'm a believer in open and honest communication.  I have always found that it builds trust and can help solve problems before they can get out of hand.  That's why I was intrigued by this article regarding patient perceptions on Medical Error disclosure. A survey of patients in Illinois revealed they would "more forgiving" if they believe their physicians would inform them of a medical error occurring. The article goes on to say that patients prefer disclosure of medical errors, but usually a "deny and defend" policy is in place when errors occur. It is hard to believe that this sort of information would be kept from patients. But according to the article, the fear of lawsuits and ruined reputation causes the lack of disclosure. 

I recently heard a story through a friend about someone who just had a baby.  After the delivery, the baby wasn't crying and all the nurses and doctors were huddled around the baby in the corner. Any healthcare professional would know this as a sign that the infant wasn't breathing and needed to be resuscitated on the spot.  Luckily the baby survived and seems to be okay.  The part of the story I couldn't believe was the mother was later told, the "baby forgot to cry."  I'm sorry...how does a newborn forget to cry?  I understand not trying to cause extra concern and worry, but I think the mother has a right to know what really happened.  How does lying about this help anyone, when there could have been some risks the parents may have needed to be aware of?

Granted, that wasn't necessarily a medical error, but it was still a situation that lacked honest communication. What this ultimately does is affect the trust between patients and physicians. If physicians are worried about lawsuits, then they won't be up front about disclosing medical errors.  Patients will have trouble trusting their physicians if they suspect secrets are being held from them. 

This lack of trust hurts communication.  I've argued that patients need to be part of the medical error feedback loop to help find where the system can be fixed.  However, this feedback loop will not be effective without that open communication and trust.  As the article encourages, policies that address error disclosure is one step in the right direction to build that trust and improve the important patient feedback channels.

Commerical Airliners and Checklists

Originally posted 11-16-2010:
While visiting our Bellevue office a couple weeks ago, I was lucky enough to find some time to tour the Boeing plant at Everett.  It's quite an amazing 90 minute tour that gives guests a chance to view the 747, 777, and 787 lines. From a balcony, you can see planes in different stages of assembly on lines that run 24/7. Looking around the monstrosity of a building, there are cranes and large machinery in place to move the large assemblies into their final place on what will become a commercial airliner. The building even has a tunnel system under the building to allow moving people and parts around.  You quickly realize that not only are these airliners an engineering marvel, but the infrastructure put in place to make it possible is awe-inspiring as well. 

A funny thought struck me as I stood, wide-eyed, taking it all in: "How many checklists does it take to manufacture an airliner?"

If you have read The Checklist Manifesto, you will understand what I mean.  In the book, Atul Gawande explores the use of checklist to help organize extremely complex real world issues like building a skyscraper or preparing an airplane for take off, and then presents a case for using checklists in healthcare. Just looking on the plant floor, the complexity of building an airplane successfully looks like a complex undertaking.  I can only imagine how many engineers were involved in the design, skilled workers involved in the assembly, and all the people needed for the logistics of bringing parts from all over the world to make it happen.  I think about all the handoffs in the process, and yet somehow in a few weeks time another airliner is rolled out of the plant for it's first successful test flight. 

Here's what really amazes me: With all of that complexity involved, those planes are pretty safe to fly in.  If those planes can be constructed in a way that is safe for passengers, why can't we get a complex system like healthcare to be safer for patients?  I realize I have written about how using comparisons to aviation has it flaws, but it represents a success story in the world of safety.  I looked at the parts and workers out on the floor, and I started thinking about patient data, equipment, processes, and healthcare workers all functioning in a system where the patient gets to their destination of being home in good health - no delays, lost items, or turbulence. I think we can get there with some standardization, good practices, discipline...and maybe a few well thought out checklists.

Under reporting medication errors

Originally posted 10-18-2010:
A series of sad news has come out of Seattle in the last month, as three different medication errors led to patient deaths at Seattle Children's.  The errors seemed to range from overdoses to wrong medications. Until the proper investigation is done, it is hard to speculate what factors could have caused these errors.  The only way to truly understand what happened is to do the root cause analysis and find where the system broke down. 

Reading about what happened led me to this article about under reporting of medication errors in the state of Washington.  According to the article, the medication error reporting law "has loopholes", making it "difficult to gauge exactly how many cases other hospitals have withheld from the health department".  This lack of reporting could be one of the flaws in the medication system that caused the errors. As Dr. Vaida states in the article, "One of the most important things is to make sure we share information about and learn from errors that happen." The culture in the state needs to be supportive of reporting medication errors without fearing punishment. Even issues in the healthcare system at this high a level can have an impact on patient care.

It is good to see legislation is being proposed to increase funding to improve the error reporting system.  Hopefully this leads to the cultural changes needed to support the sort of reporting that will allow caregivers and healthcare administrators to find ways to improve patient safety.

One other thought on this.  I hope one of the improvements is an easier to use reporting system. It is often the case that software put in place to report such errors is not very easy to use, causing it to be a hindrance to reporting.  Through some of the research I have done, I have heard many health care professionals talk about systems full of long forms that take too much time to fill out.  The technology has to fit in the process in a way that it will not lead to more under reporting. 

Patient Safety beyond the Hospital

Originally posted 9-21-2010:
As I have been writing this blog and reading up on Patient Safety research, I have noticed that much of the work has been done for hospital settings.  This makes a lot of sense, as the most critically ill patients and most intensive procedures occur in inpatient settings.  However, most patients do not get admitted to the hospital. Instead, a majority of patients are seen in an outpatient setting - primary care clinics, same day surgeries, or even a visit to the local pharmacy.  But as I recently wrote, a medical error can occur outside of the hospital walls.

That's why I found this recent New England Journal of Medicine article by Drs. Gandhi and Lee to be very interesting.  The article focuses on the lack of Patient Safety research in ambulatory care settings and addresses some of the safety challenges in that healthcare environment. 

One of the main takeaways is the lack of information sharing that goes on between different care settings.  These days a patient could be seeing a couple specialists, but none of them may be aware of the care and treatment from the other physicians.  As Electronic Health Records (EHRs) are mentioned more and more for hospitals, I hope health systems are also looking at including them in their clinics so there are not any information disconnects in patient care.

Additionally, the article mentions "an increasing number of complex procedures are now being performed as day surgery or in nonhospital locations."  Because of this increase in the amount of day surgery centers, it is getting on the radar of HHS to look at ways to reduce Healthcare Associated Infections (HAIs) in these settings.  The attached .pdf was a presentation from the NPSF conference, and it is clear that initiatives for HAI reduction in ambulatory settings is on the horizon.

I was also glad to see the article highlight the need for patients to get involved in their own care.  Some healthcare systems have developed "innovative approaches to engaging patients in their own care."  The primary example are the health record portals in which patients can view their own test results, view their medications, and monitor their care.  I have written on here before that patients need to be part of the feedback loop to prevent a medication error from causing harm.  This is even more important in the ambulatory care setting where a care giver is not monitoring the patient on a regular basis.

Finally, I was happy to see the authors highlight the need for the ambulatory setting to embrace a culture of safety.  Creating a culture of safety has been identified as one of the biggest, but most important challenges to improving Patient Safety.  Culture change has been a common theme in much of what I have across in my Patient Safety research, from attending the NPSF conference to reading books such as "Why Hospitals Should Fly". 

Overall, this article was a good read and provides a nice way to raise awareness that safety issues can occur in any aspect of healthcare.  It seems that we are only seeing the tip of the iceberg in making changes to improve the safety of the ambulatory care environment.

Where does your hospital rate?

Originally posted 9-12-2010:

Typically when I am about to make a big purchase, I do a lot of research before making a final decision.  If I am looking at a new car, I like to compare between a few different models to see which one is safe, reliable, fuel-efficient, a good value, and fun to drive.  Camping and outdoor gear is something I don't mess around with - I'm looking for something that is lightweight and won't get ruined in the rain. My running shoes need to fit well, have good stability, and get me through the multiple miles that comes with marathon training.  I'm pretty sure I am not the only one that will do this sort of research when it comes time to make a big purchase.   Everyone wants to have their criteria met without breaking the bank.

But does anyone do this when it comes to where they go to see their healthcare provider?  Do you do the same sort of "shopping" if you know you have an upcoming operation or necessary hospital stay?  To be honest, I never have.  In the past I would look for the clinic or hospital that was closest to where I was at.  I essentially looked for convenience more than anything else.

I recently realized it is possible to "shop" for my healthcare using quality of care and patient experience as criteria. The US Department of Health & Human Services has a site called Hospital Compare to allow patients to compare hospitals in their area.  The site covers all sorts of quality of care criteria and includes a survey of patient experiences at the facility.  Do you want to know if your hospital is giving their patients the correct antibiotic at the correct time before a surgery?  You can find that out.  Other criteria to compare are whether or not patients experiencing chest pain are getting aspirin 24 hours of arrival or are getting an antibiotic within 6 hours if they have pneumonia.  There are benchmark comparisons with the national averages of mortality rates for specific conditions.  To top it off, the site shows the results of a survey of patient experiences.  Not only can patients now gauge the effectiveness of the care they will receive, they can also get a sense of the quality of care. And if anyone needs a second opinion, Consumer Reports is in the healthcare "shopping" game as well.  Their site requires a membership, but it provides another unbiased source of information to help choose the best hospital for the needed care.

I think this is a great resource for patients.  I realize not everyone has the chance to make a choice on where they go for their care.  In rural areas, patients may only be able to go to the nearest hospital.  And health insurance may dictate where a patient can go for their care.  For those lucky enough to have a choice, this provides a nice comparison to help decide where to get the safest healthcare.  Not only does it point to where to get safer care, but now hospitals will now have more accountability to provide the safest and highest quality care possible.  I would like to think this will lead to patients creating a demand for higher quality and safer care.

It is a nice feeling knowing that in the future I can go shopping for what could be a pretty important decision.