Patient Safety Blog

Tara Parker-Pope of the NY Times has an article on how more than half of the writers of the DSM-IV--the Diagnostic and Statisical Manual of Mental Disorders--have financial links to the drug industry.

The DSM is the most commonly used handbook of psychiatric disorders. Clearly these financial links suggest a conflict of interest.

From the article:

It’s not the first time the D.S.M. has been linked to the drug industry. Tufts University researchers in 2006 reported that 95 — or 56 percent — of 170 experts who worked on the 1994 edition of the manual had at least one monetary relationship with a drug maker in the years from 1989 to 2004. The percentage was higher — 100 percent in some cases — for experts who worked on sections of the manual devoted to severe mental illnesses, like schizophrenia, the study found.

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Posted In: Medications

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There is a growing industry of hired patient advocacy. Patients are hiring people to defend their interests when they go to the hospital.

The impetus from this comes from the huge number of patients who die because of medical error, and the growing consensus that going into a hospital as a patient alone is one of the most dangerous things you could do.

From the article:

It is a trend emerging here and across the country, though it's not without controversy — and a hefty price tag. But it may be offering a vital, even lifesaving service in a severely overburdened medical system plagued by a shortage of nurses, doctors and hospital beds. Arizona — with the nation's longest ER wait time and an extreme shortage of doctors and nurses — should prove fertile for the fledgling business. "We have seen so many patients — including my own father and mother — nearly die in the hospital because of mistakes or neglect, we realized somebody had to do something," said Alice Milton, a Tucson attorney now working for Patient Care Advocates, a company launched two years ago in Tucson — first to provide home care services, expanding to hospital patient advocacy in recent months. "This idea was born of personal trauma, of seeing firsthand what kind of fight you have to wage to get decent care for someone you love. And of seeing patients who are absolutely terrified to go to the hospital, because they are certain they will die there," Milton said. "The need for this is huge — great enough to actually earn a living doing it."

Of course, savvy family members and other loved ones can also serve as your "advocate," with the added benefit that they will probably do it for free. But the idea is essentially the same: when you go to a hospital, it is comforting and may even be life-saving to have back-up with you.

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Posted In: Standard of Care--Hospitals

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Lasik is a popular laser surgery done on the eyes to correct vision. However, last week Lasik patients went to Washington D.C. to speak to the Food and Drug Administration on harmful side-effects that they experienced as a result of the surgery, including the following:

(1) Severe eye pain

(2) Dry eye

(3) Blurred vision

The effects of intense chronic pain can have a devastating effect on people's lives. One case was particularly extreme. From the article:

Colin Dorrian was in law school when dry eye made his contact lenses so intolerable that he sought Lasik, even though a doctor noted his pupils were pretty large. Both the dry eye and pupil size should have disqualified Dorrian, but he received Lasik anyway -- and his father described six years of eye pain and fuzzy vision before the suburban Philadelphia man killed himself last year.

"As soon as my eyes went bad, I fell into a deeper depression than I'd ever experienced, and I couldn't get out," Gerard Dorrian read from his son's suicide note.

One quoted patient said he was considered a "success" by doctors despite experiencing terrible after-effects:

Matt Kotsovolos, who worked for the Duke Eye Center when he had a more sophisticated Lasik procedure in 2006, said doctors classify him as a success because he now has 20-20 vision. But he said, "For the last two years I have suffered debilitating and unremitting eye pain."

These patients are demanding clearer standards for who can qualify for Lasik, as well as better information from the FDA on how many patients suffer these various side-effects.

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Posted In: Surgery

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Christina Laun at RN Central has made a helpful list: 25 Tips to Help Protect Yourself from Medical Errors.

Reading the entire list is a good idea. But many of the items on the list can be boiled down to two principles: 1) be an active participant, and 2) don't be afraid to seem entitled or pushy in demanding knowledge of what is going on. Don't be afraid you're annoying your doctor by asking questions, for instance. Speak to every member of your surgery team and make sure they know what they're doing--do not simply trust, and remember that there is no reason to feel ashamed or embarrassed about asking questions.

Furthermore, bring family or friends to support you, if you can. If you're ill, you may not be able to do the things on the list yourself. Having someone to ask the questions you don't think of and notice the things that you don't notice is an invaluable asset.

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Posted In: Medical Error

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Pain is a tricky medical problem because it's impossible to measure or adequately communicate to another person. Tara Parker-Pope discusses how patients in pain use art to describe what they're going through:

Sacramento resident Mark Collen, 47, is a former insurance salesman who suffers from chronic back pain. After his regular doctor retired due to illness, Mr. Collen was struggling to find a way to communicate his pain to a new doctor. Although he has no artistic training, he decided to create a piece of artwork to express his pain to the physician. “It was only when I started doing art about pain, and physicians saw the art, that they understood what I was going through,” Mr. Collen said. “Words are limiting, but art elicits an emotional response.'’ Mr. Collen wrote to pain doctors around the world to solicit examples of art from pain patients....

...Finding ways to communicate pain is essential to patients who are suffering, many of whom don’t receive adequate treatment from doctors. In January, Virtual Mentor, the American Medical Association Journal of Ethics, reported that certain groups are less likely to receive adequate pain care. Hispanics are half as likely as whites to receive pain medications in emergency rooms for the same injuries; older women of color have the highest likelihood of being undertreated for cancer pain; and being uneducated is a risk factor for poor pain care in AIDS patients, the journal reported.

The subjective nature of pain means that doctors often feel inclined to dismiss it, or assume that the patient is lying or exaggerating, especially if it fits in with the doctor's preconceived stereotypical beliefs. It is therefore vital that doctors respect what patients say about their pain. If you are a patient, there is no need to feel shy about insisting forcefully that you are in pain: that is an area within your expertise, not the doctor's.

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Posted In: Communication

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Federal officials have identified the contaminant that was found in the blood-thinning medication heparin in 11 countries.

Chinese officials have denied that this contaminant has caused any deaths. As for U.S. officials, here is what one of them says:

Dr. Janet Woodcock, director of the Food and Drug Administration’s drug center, said that German regulators uncovered a cluster of illnesses among dialysis patients who took contaminated heparin. She said Chinese officials had conceded that heparin produced in their country contained a contaminant, though they say it was not connected to the illnesses.

“Heparin should not be contaminated, regardless of whether or not that contamination caused acute adverse events,” Dr. Woodcock said. “We are fairly confident based on the biological information that we have had that this contaminant is capable of triggering these adverse reactions.”

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Posted In: Product Safety

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In California, regulators ordered insurers to reinstate the policies of 26 patients who allegedly lied on their applications.

As Michelle Andrews notes in the linked article, insurers will often claim that a patient "lied" about something that was either an honest mistake or the result of the insurer using strange definitions. For instance:

...one woman I spoke with on this topic had answered "no" when asked if she'd been treated for cancer in the past 10 years. Later her policy was yanked because the insurer claimed that regular blood work she had to ensure her earlier cancer hadn't returned constituted cancer treatment.

One might guess that this phenomenon occurs in other states as well. Andrews comments that patient advocates suspect it does.There is certainly no evidence indicating that it is confined to California.

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Posted In: Insurance

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The New York Times has an interesting article about the recent decision of some scientists to refuse payments from the pharmaceutical and medical device industry. From the article:

No longer will they be paid for speaking at meetings or for sitting on advisory boards. They may still work with companies. It is important, they say, for knowledgeable scientists to help companies draw up and interpret studies. But the work will be pro bono.

The scientists say their decisions were private and made with mixed emotions. In at least one case, the choice resulted in significant financial sacrifice. While the investigators say they do not want to appear superior to their colleagues, they also express relief. At last, they say, when they offer a heartfelt and scientifically reasoned opinion, no one will silently put an asterisk next to their name.

The entire article is worth a read. If more and more scientists do this, then patients researching their conditions and curious laypeople will have one less cause for skepticism about what they're being told.

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Posted In: General

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Tara Parker-Pope has an article on the privacy implications of big companies like Microsoft and Google entering the medical records storage business. We have discussed this issue before, stressing the importance of patients needing convenient access to all of their medical records.

Parker-Pope, however, discusses a potential downside to this development: a loss of privacy for patients. Violations of medical privacy have been in the news lately. See, for instance, UCLA Medical Centers' employees' violations of the privacy of several well-known patients. If data is stored in Web-based systems by the same companies that track users' online activities, what kind of privacy can patients expect? These concerns become even more pressing when you consider that HIPAA--the law that guards patient privacy--did not anticipate and most likely will not apply to these proposed personalized Web-based systems. As Parker-Pope comments:

Even more surprising is the response of Peter Neupert, the vice president in charge of Microsoft’s health group, who resisted the suggestion of extending Hipaa to newcomers like Microsoft and Google.

This resistance is predictable but disturbing, to say the least. Privacy should be a huge concern for both creators and users of these systems, and customers should insist on Google and Microsoft addressing these issues.

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Posted In: Medical Records

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Tara Parker-Pope in the New York Times reports on a study by British researchers investigating what questions patients felt comfortable asking their doctors.

Questions that did not imply anything about the doctor's preparation or experience or authority were easy to ask--for example, questions about length of stay, or details about how a procedure worked. However, other questions were tougher:

But questions aimed at improving patient safety and reducing medical errors were far more difficult for patients to ask, receiving an average score of just 2.4 points. Questions that received low marks included:

* “Who are you, and what is your job?”
* “I don’t think that is the medication I am on. Can you check please?”
* “Have you washed your hands?”
* “How many times have you done this operation?”

The abstract of the study, published in the journal Quality and Safety in Health Care, can be found here: How willing are patients to question healthcare staff on issues related to the quality and safety of their healthcare? An exploratory study

It is clear that, as hand-washing and double-checking medications are important safety protocols, patients need to become more assertive and doctors and nurses need to become less defensive and more open to these kinds of questions.

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Posted In: Standard of Care--Hospitals

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A new survey on patients' opinions on their hospital stays has some disturbing results:

Many patients reported that they had not been treated with courtesy and respect by doctors and nurses; that they had not received adequate pain medication after surgery; and that they did not understand the instructions they received when discharged from the hospital.

Nationwide, in the average hospital, 67 percent of patients said they would definitely recommend the institution where they had been treated to friends and relatives. Sixty-three percent gave their hospitals a score of 9 or 10 on a scale of 0 to 10.

At the average hospital, more than 25 percent of patients said nurses had not always communicated well with them.

There is more at stake here than the patients' feelings, as Dr. Carolyn Clancy notes:

“Poor communication is a major source of medical errors,” Dr. Clancy said. “If doctors are not listening carefully, patients may not bring up important information. Patients who do not understand discharge instructions are more likely to be readmitted to the hospital or end up in the emergency room.”

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Posted In: Standard of Care--Hospitals

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Vesna Jaksic has an interesting article on Law.com on potential problems with binding arbitration agreements between doctors and patients, wherein patients sign away their right to a jury trial.

From the article:

Binding arbitration agreements between doctors and patients -- in which patients waive their right to a jury trial -- are becoming more common, a trend that could put patients at a disadvantage if medical malpractice disputes surface, attorneys warn.

A growing number of physicians, nursing homes and health care institutions are asking consumers to sign these agreements before offering services, said Stuart Ratzan of Miami's Ratzan & Rubio.

Some states have passed or are trying to pass legislation that would limit how these agreements are used. For instance, an act waiting for congressional approval in Washington D.C. would require (among other things) that the costs associated with arbitration be disclosed in the arbitration agreement. This is important because the patient must pay for arbitrators to do their job, whereas they do not have to pay for judges and juries.

It would be particularly disturbing if these agreements became common enough that people cannot get medical care without signing one.

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Posted In: Medical Error

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