Patient Safety Blog

That question is now on trial in a small west Texas town, where a nurse stands accused of a felony for reporting a doctor whom she thought was guilty of malpractice on patients. Even if the nurse is acquitted, the case could have a chilling effect on nurses' willingness to act as whistle blowers when they see sub-standard medical care.

The defendant, Anne Mitchell, R.N., was indicted for "misuse of official information," a felony, because she reported to the state medical board her concerns about the quality of care delivered by Dr. Rolando G. Arafiles Jr.

Nurse Mitchell worked in quality of care issues for the Winkler County Memorial Hospital where both she and Dr. Arafiles worked.

The case is being followed closely by the Texas Nurses Association, which raised money for the defense of Ms. Mitchell. Click here for case updates.

When the indictment was first reported last summer against Ms. Mitchell and a second nurse (whose charges were recently dropped by the local prosecutor), the American Nurses Association also spoke out strongly.

“ANA wants Winkler County to know the world is watching – we will be monitoring this case closely in the hope that the apparent abuse of prosecutorial discretion will be corrected,” said ANA President Rebecca M. Patton, MSN, RN, CNOR. “It is outrageous to file criminal felony charges against these nurses based on allegations that they raised concerns over a physician’s actions. This undermines one of the basic tenets of the nurse’s Code of Ethics – nurses have a duty to advocate for the health and safety of their patients, and that is what these nurses were doing.”

The New York Times detailed Ms. Mitchell's concerns with Dr. Arafiles' practices in a recent article by Kevin Sack, which also discusses the bigger picture for quality of medical care.

Nurses are traditionally seen as patient safety advocates. That role needs to be nourished, not threatened, for the sake of all patients.

Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: Health Care Reform

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The best measure for understanding what Americans spend on health care is the health care share of GDP (Gross Domestic Production). When that share crossed the 10 percent thershold in the early 1980s, plenty of economists sounded the alarm that ruin was ahead if we couldn't somehow make that share stable, so the rise in health care spending kept pace with the economy but didn't take a bigger and bigger piece of the pie.

So how are we doing? Health care's share of the economic pie went up to 17.3 percent of GDP in 2009, according to a new report in the respected journal Health Affairs. It's the biggest single-year increase since 1960.

The Wall Street Journal's Health Blog crunched some numbers and reported:

The U.S. spent $2.472 trillion on health care last year, according to a paper out today in the journal Health Affairs. That’s $282 million an hour.

Health spending as a percent of GDP — a key metric that shows how much of all U.S. spending goes to health care — rose from 16.2% in 2008 to 17.3% in 2009, far higher than any other industrialized country. That’s the largest one-year increase since 1960, when the feds started closely tracking national health expenditures.

The figure went up so much because health spending continued to rise, even as the overall economy shrank. The aging population accounted for a small part of this rise, but two other factors were more important: rising prices and increasing use. Health-care prices rose by 3.2% in 2009, according to the Health Affairs paper, significantly faster than prices rose for the overall economy. Utilization, which includes both volume and intensity of health-care services, rose by 1.5%.

The share of health-care spending paid for by the government (through programs such as Medicare and Medicaid) is also rising, and is projected to cross the 50% threshold soon.

The share of the economy for health care will be close to 20 percent within the next 10 years, according to government forecasters.

These sobering numbers show the urgency of "bending the cost curve down," as the pundits like to say. Unfortunately the urgency of reforming the safety and quality of health care has taken a far back seat to the money discussion. They actually are compatible goals. One thing we've learned in the health care reform debate is the huge overspending in health care caused by widespread use of new technologies before their benefit is proven, driven in part by conflicts of interest by those pushing the new technologies.

Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: Accessibility of Healthcare , Health Care Reform

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Measured by results -- preventable deaths and injuries due to malpractice, medical errors, preventable infections, misdiagnosis and other events that shouldn't happen -- American health care has a lot of problems. Millions of patients are injured every year, and upwards of 200,000 patients die annually from preventable errors and hospital-acquired infections. The United States also lags far behind other developed countries in basic health outcome measures like life expectancy and infant death rates.

But when U.S. hospitals measure themselves with a different yardstick -- the "process" measures of how often certain important things get done for commonly treated diseases -- the results are astoundingly good. An annual report from the Joint Commission, the agency that inspects and accredits hospitals, finds steady improvement in the "process" quality measures that it looks at -- with most hospitals now performing in the 99% range on things like how often heart attack patients get standard treatments in the ER like aspirin and beta-blocker drugs.

The Joint Commission now measures 31 quality indicators. They cover the most common hospitalizable conditions: heart attack, heart failure (when the pump isn't pumping effectively), pneumonia, surgical care, and children's asthma. You can go to this website to look up information about a particular hospital.

The problems with the report are:

* Data is reported voluntarily by the hospitals, with no independent audit from anyone other than the Joint Commission. The Joint Commission says it's independent from the hospital industry but is often seen by critics as a cheerleader.

* Outcome measures -- deaths and injuries -- are not included in the report. Even infection rates, which could have required reports if Congress ever passes health care reform, are not yet reported.

Consumers Union has a Safe Patients Project. CU says it's high time for the U.S. health care industry to be required to report its results. Patient advocates like me agree wholeheartedly.

Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: Health Care Reform , Hospitals , Medical Malpractice , Standard of Care--Hospitals

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The deadly MRSA infection, estimated to kill 19,000 Americans every year (more than the toll from AIDS), has been virtually wiped out in Norway, with three simple steps:

As described in a recent Associated Press article:

Norway's model is surprisingly straightforward.

-- Norwegian doctors prescribe fewer antibiotics than any other country, so people do not have a chance to develop resistance to them.

-- Patients with MRSA are isolated and medical staff who test positive stay at home.

-- Doctors track each case of MRSA by its individual strain, interviewing patients about where they've been and who they've been with, testing anyone who has been in contact with them.

Step No. 1, ratcheting back on antibiotic prescriptions and relying more on the old tried-and-true ones, won't go over well in America, where the prescription drug industry pushes all of us into a newer-is-better and more-is-better approach.

But step No. 2 -- test and isolate -- has been proven to work by itself to virtually wipe out the spread of MRSA once it gets into a hospital, by isolating people who are carriers.

The problem is that people can carry the bug on their skin without harm; a deadly infection only happens when it gets into the body of an already vulnerable patient. The answer: do nasal swabs of all incoming patients when admitted to the hospital to see if they are carriers, and if so, isolate them in special units.

Does your hospital do this? If not, you should ask why not. The safest hospitals in the United States do nasal swabs of all incoming patients at the time of admission. It's for their safety and everyone else's.

Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: Health Care Reform , Hospitals , Infections

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Actor James Woods' brother Michael died of a heart attack three years ago in an emergency room hallway in Rhode Island because no one was paying attention. Now, something good will come from Michael Woods' death, thanks to a settlement reached between the Woods family and Kent Hospital in the middle of a jury trial.

The settlement creates a new institute to help teach hospital staff how to pay better attention to patients and develop a more "human-centered" standard of care.

An impasse between the two sides in the trial was broken when the president of the hospital, Sandra Coletta, called James Woods the night before the actor was going to testify about his brother's death. As reported in the Providence Journal:

In that call, he said he heard something he’d never heard from Kent Hospital before, someone saying she was sorry for his family’s loss. ... Woods said the family’s peace of mind about the agreement was helped when Coletta met his mother, Martha.

“Sandra and my mother had a very personal moment, a mother-to-mother conversation,” Woods said, calling it a “sweet and dear way to express sorrow.”

“It was all I ever needed to see in my life,” Woods said, “one human being saying to another human being ‘I’m sorry for your loss.’ ”

In announcing the new Michael J. Woods Institute, which will be funded by $1.25 million of the hospital's money, hospital president Coletta said:

"We know we're not perfect at Kent Hospital. Mistakes were made. We can do better. The Michael J. Woods Institute will help establish a leadership role in promoting patient safety and developing new ways to improve the patient experience and clinical outcomes."

This is one often-overlooked benefit of the civil justice system: producing positive safety reforms to try to reduce the toll of medical error. An actor's celebrity helped make that a reality in Rhode Island. On a quieter level, similar positive events happen at the end of many lawsuits, where families who have lost a loved one insist that part of the settlement go toward education and system reforms to make hospitals safer places. Patient safety advocates like me believe this is one of our highest callings.

Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: Health Care Reform , Heart Disease , Hospitals , Standard of Care--Hospitals

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How is our medical care system like American agriculture before the era of modern food-growing practices? Pretty similar, argues Dr. Atul Gawande in the New Yorker. Both were expensive, wasteful of human resources and completely fragmented. And the cures for their problems could be similar too.

What reformed American farming and turned it into a world leader in producing low-cost food was the "extension" system that the government set up for teaching farmers, one county at a time, what worked and what didn't work.

Dr. Gawande argues that the 2,000-page health care reform bill now in Congress has an optimistic prospect for using many pilot projects in funding health care to figure out what works to lower costs and increase safety and quality. It's a fascinating argument, and I hope he is right.

I only differ from Gawande on one thing: he takes swipes at malpractice attorneys and the lawsuit system as contributing to the waste. That has not been borne out by careful studies. Moreover, patients need a robust system of advocacy for when preventable injuries have occurred. So far, no better system has been developed for getting to the bottom of what happened, to try to prevent it from happening again, and to give the patient fair compensation.

Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: Health Care Reform

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A piece by a doctor in Salon.com puts the lie to claims from the medical industry that a dose of "tort reform" to curb medical malpractice lawsuits will lower medical costs and make for safer health care. Quite the opposite, as pediatrician Rahul K. Parikh, M.D. explains. Two short excerpts below from his article, which is worth reading in its entirety:

Their refrain [of the AMA leaders] is familiar to anybody following the healthcare reform debate. The only problem is that it's not true. There's nothing "sure or quick" about changing medical liability laws that will improve healthcare or its costs. Defensive medicine adds very little to healthcare's price tag, and rising malpractice premiums have had very little impact on access to care.

...

Tort reformers neglect the fact that malpractice reform won't save one extra life. To make that difference, insurers, doctors and their lobbyists like the AMA need to find ways to improve patient safety. So for those who push tort reform as a panacea for a sick healthcare system, working to prevent injuries is a much more noble pursuit than writing up baseless arguments for the back pages of a newspaper [in this case, the Wall Street Journal].

Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: Health Care Reform

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