Patient Safety Blog

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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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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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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In a previous entry, we discussed the phenomenon of a form elder abuse in nursing homes wherein staff give anti-psychotics elderly patients without psychotic disorders in order to make them easier to deal with.

Earlier this month, a study was released following up on that, showing which states have the highest rate of this form of abuse. Louisiana and Connecticut head the list, with Florida, Pennsylvania and New Jersey below the average.

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Two recent events highlight the need for easy access to information about a hospital's record of mistakes and violation of standards.

The Florida Supreme Court ruled on Thursday March 6th that patients have a right to see records on past mistakes made by hospitals and health care providers, including very old records, and that laws limiting access to such records are unconstitutional.

In more disturbing news, the Endoscopy Center of Southern Nevada violated hygiene protocols and, consequently, six cases of hepatitis C have been traced back to them. The linked editorial argues that detailed, publicly available information on medical centers and health care providers--standards, inspection results, past errors--is necessary for public trust in medical institutions.

Unfortunately, the Centers for Disease Control and Prevention has issued a warning that the Nevada incident may not be an isolated incident. It is likely that these safety problems exist in other clinics all over the country.

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When AIDS was first discovered and little was known about it, that ignorance resulted in a great deal of paranoia, ostracism and cruelty towards AIDS patients.

Now, more than two decades after we have known about AIDS and during which the disease has been studied and treated if not cured, we might be tempted to say that AIDS no longer carries its stigma. But we would be mistaken. A new study shows that AIDS patients continue to be insulted and demeaned by doctors, nurses and other health care professionals who ought to know better. From the article:

Examples include doctors who would not visit a patient's hospital room, neurologists who avoid looking patients in the eye, and ambulance personnel who madly threw bloodied gloves into the street after learning the injured patient carried the virus.

These instances of stigmatic events are described in the study conducted by Lance S Rintamaki of the University at Buffalo and colleagues. The study participants report several of these events, which include a wide variety of health-care personnel. "Clinicians should have the training and common sense to avoid a lot of these behaviors, but perhaps we shouldn't be surprised when hearing about nonclinical staff caught up in these events. They're likely relying on the same stereotypes and misinformation about HIV that are commonplace among the general public, which may lead them to act in fearful and stigmatizing ways toward HIV-positive patients," says Rintamaki.

This is discouraging news in the year 2008. AIDS patients and their loved ones should be prepared for these reactions and should take special care to insist on proper treatment.

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Bedsores, a common hospital problem, are not just ugly nuisances. They can turn into deep and extremely painful wounds that go clear to the bone, and can be fatal when infected.

That is why it is encouraging to find that hospitals and nursing homes are beginning to take a highly effective collaborative approach towards preventing bedsores. From the article:

New research is suggesting that the battle against bedsores requires a team approach, enlisting everyone from nurses and nursing assistants to laundry workers, nutritionists, maintenance workers and even in-house beauticians.

For instance, laundry workers can be in a position to notice when patients' garments are restrictive and ill-fitting, which increases the likelihood of bedsores. All staff can help by repositioning patients during waits for food and other services. Proper nutrition goes a long way towards helping this problem as well, research suggests.

As this blog has discussed in the past, collaborative efforts can be helpful to all kinds of medical problems. Evidently such approaches are useful in dealing with this painful issue as well.

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The Centers for Disease Control and Prevention (CDC) has an article on hand hygiene. Much of it is somewhat technical, categorizing different types and levels of sterilization precautions and measurements of efficacy.

If you scroll down, however, there are quite a few practical details that may be helpful. Much of it is common sense: fingernails that are long or artificial, for instance, have been linked to outbreaks of infections and the presence of pathogens. If you wear a ring, the skin under the ring is more likely to be colonized with bacteria than the rest of your hand. And, of course, wearing gloves play an important role in maintaining good hygiene.

If you scroll down even further, you'll get to Part II of the report, which is the CDC's recommendations about how to maintain hygiene in various professional contexts.

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If the number of emergency rooms go down and the number of medical emergencies rise, it stands to reason that the average waiting time in emergency rooms would get longer, resulting in more problems and even deaths. That is exactly what is happening right now in the U.S, as a new study from Harvard Medical School demonstrates.

In 1997, half of all patients waited for 22 minutes or more in the emergency room. Today, they wait for 30 minutes or more.

Most disturbing is the fact that even patients with the most dire and urgent problems are subjected to greatly increased waits. From the linked article:

Even those experiencing a heart attack are not assured speedy treatment, with half waiting 20 minutes or more to be examined in 2004, up from eight minutes in 1997, the study found. The same was true for those with other serious health problems: By 2004, patients whose conditions warranted treatment within 15 minutes were waiting 14 minutes or more to see a doctor, up from 10 minutes in 1997, the study found.

These longer waits are due to a number of factors: shortage of doctors and nurses, an aging population, and the fact that for uninsured Americans the emergency room is the only method of accessing healthcare. So not only do more people go to the emergency room for non-urgent problems, but many Americans also do not have access to the preventative care that would reduce the risk of serious emergencies that need to be dealt with right away.

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Out of nineteen industrialized nations, the U.S. has the most deaths that could have been prevented by access to timely, effective medical care.

Ellen Nolte and Martin McKee of the London School of Hygiene and Tropical Medicine performed the study, looking at deaths before the age of seventy-five caused by numerous diseases and complications. They found that France performed the best by this measure--though France, and other countries that ranked higher than the U.S., spends less money on health care than the U.S. does.

Not only was the U.S. the worst in these rankings, but we Americans are also ranked four places lower than we were in the last study (which covered 1997 and 1998). We are getting worse and spending more money.

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Posted In: General , Medical Error , Medications , Standard of Care--Hospitals , Surgery

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By January 1st of this year, Illinois was to have established a system for reporting and reviewing egregious hospital errors--e.g. sponges left inside patients after surgery. But it has not done so. Illinois has also failed to fulfill other elements of the hospital safety legislation the state passed four years ago. For instance, the Illinois Hospital Report Card was supposed to have been published, but is nowhere to be seen. Illinois officials are now predicting that it will be released in October.

Officials blame this failure on everything from poor leadership to lack of funding to unrealistic expectations. Whatever the cause, the failure is disappointing because--as the Consumers Union health-care expert Lisa McGiffert points out--Illinois was regarded as a role model for other states in this area.

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It is safer to have a heart attack in an airport or casino than in a hospital.

Why? One reason is that many hospitals still rely on old-fashioned defibrillators rather than the newer ones found in public places. The new ones are fully automated, faster and easy to use.

Chances of surviving a heart attack are nearly 40 percent if you are defibrillated within two minutes of the attack--but fall to 22 percent if it takes longer. Hospital staffs in the study took longer than two minutes in nearly one third of all cases.

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What happens when a hospital makes a mistake in medical care, and the harm to the patient results in the need for another medical treatment? It used to be that the patient was charged for this subsequent treatment, which would have been unnecessary but for the hospital's error. An article in the Journal of the American Medical Association (JAMA), cited in the New York Times discusses the economics of this system. Indeed, the system is set up so hospitals are financially rewarded for their mistakes.

But as the NY Times article points out, Medicare has changed its rules so that it will no longer compensate hospitals for the following mistakes: objects left in patients during surgery, incompatible blood transfusions, infections from vascular catheters and other hospital-acquired problems. This does bring up the potential problem of hospitals not having financial incentive to provide good care for these medical problems, but there are laws in place mandating that hospitals provide such care, so that may not be as much of a problem as some would fear.

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Shockingly, nursing homes having been giving elderly residents anti-psychotic drugs--not to combat actual psychosis, but rather to quiet symptoms of Alzheimer's or other forms of dementia and make the patients more docile and controllable.

This overuse of anti-psychotics is so rampant that it accounts for why Medicaid has recently spent more money on anti-psychotics than on any other type of pharmaceuticals.

This is not wholly due to malicious intent on the part of the nursing homes, but also on the fact that federal insurance programs are more willing to give money for drugs rather than for the extra staff that are needed to care for elderly patients with dementia.

This report highlights how medical institutions can harm the most vulnerable patients by giving them medications they do not require in order to meet economic or administrative goals.

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Posted In: Medications , Standard of Care--Hospitals

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An article in the New Yorker by Atul Gawande highlights the simple ways in which hospitals can be made less dangerous places for their patients. A checklist to make sure intensive care doctors and nurses handle catheters correctly has been proven to dramatically reduce the risk of deadly infections. Gawande focuses on the work of Peter Pronovost, MD, an intensive care specialist at Johns Hopkins Hospital who consults with hospitals around the country to spread his gospel of routinizing simple procedures. For example, on catheter infections, Pronovost's work was first published in December 2006 in the New England Journal of Medicine. In 108 ICU's across Michigan, they were able to virtually wipe out catheter-based infection by enforcing a required checklist of five interventions: hand-washing before handling a catheter, full-body draping when inserting a central venous catheter, scrubbing the skin with chlorhexidine, avoiding catheters in the groin, and removing unneeded catheters as soon as possible. All hospitals should implement these simple ideas which can prevent deadly infections and save lives. Dr. Pronovost is a pioneer in patient safety research.

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Posted In: Communication , Infections , Standard of Care--Hospitals

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Hospitals have been getting some negative attention recently as a result of their high rates of infection. That is why it is good to hear that they are stepping up efforts to fight MRSA, one of the worst "superbugs" that infect patients in hospitals.

Their efforts can be boiled down to two categories: testing and hygiene. They are trying to make it a common practice to test surfaces and equipment and patients for the presence of these bugs. They are also encouraging hygiene by placing alcohol sanitizer dispensers in hallways and outside patient rooms, and by placing secret observers to watch if their doctors and nurses are washing their hands as often as they are supposed to.

Patients cannot do very much to ascertain whether or not their hospital is testing for MRSA, but hygiene is often much more obvious. A careful patient or family member should watch and see if there are sanitizer dispensers in their hospital's hallways, and if the healthcare providers are taking advantage of these dispensers. You should not hesitate to ask if the doctor or nurse has washed their hands, or to complain if you know that they have not. Such basic measures can prevent deadly infections.

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Rhode Island Hospital has, for the third time this year, done a brain surgery on the wrong side of the patient's head.

The hospital has been fined $50,000 and has received a reprimand from the state Department of Health. In this most recent instance, the patient was 82 years old. Fortunately, the patient was unhurt by the mistake. However, in one of the previous instances of this mistake at this hospital, the patient died as a result.

Rhode Island Hospital has said that it will be conducting a review of its procedures and implementing reforms. One such reform would be to allow nurses greater power in ensuring that procedures are followed correctly. Another would be to mandate better verification of surgery plans, which would require better communication between surgeons and other doctors. These reforms highlight a major factor in averting medical errors: teamwork. The multiple healthcare professionals involved in taking care of a patient need to be empowered to speak up if they see something going wrong. They also need to know what the others are doing, and to make sure that they are not acting contrary to the recommendations and instructions of other healthcare providers. Performing a surgery on the wrong side of the head is only one possible thing that could go wrong in the absence of communication. Another example would be giving a patient medications that, combined with medicine the patient is already taking, could cause problems. Such errors can be minimized through proper communication between healthcare professionals.

For more information: When Surgeons Cut the Wrong Body Part

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Posted In: Medical Error , Standard of Care--Hospitals , Surgery

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Going to a hospital and getting even sicker is an all-too-common occurrence for many in the U.S.A., thanks to the high hospital infection rates.

Indiana University School of Medicine researcher Dr. Bradley Doebbeling is using a $400,000 grant to study this problem and come up with solutions. The study will take eighteen months and will require participating hospitals to come up with better hand hygiene policies and screen patients for MRSA (methicillin-resistant Staphylococcus aureus). MRSA is the most common example of what is known as a “superbug,” a strain of bacteria resistant to antibiotics.

Participating hospitals will also have to record the number of patients who get MRSA—something federal and state governments do not require hospitals to do.

The hospitals in the study say that they are already noticing results. This is unsurprising considering how straightforward the study’s experimental policies are: hand-washing and screening. Learning that such basic measures help prevent sickness is hardly a massive discovery.

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Infections contracted in hospitals can be a serious threat to patients' health. The CDC estimates that roughly two million patients per year develop infections in hospitals, out of which approximately 90,000 per year die. The Consumers' Union discusses how many states have adopted laws requiring hospitals to disclose rates of patient infection, and how more states are considering such measures.

Disclosing infection rates will hopefully lead to better patient safety and stronger compliance with prevention protocols. It is a good idea for people to remain aware of the infection rates at local hospitals.

Thankfully, some hospitals are beginning to fight the problem more aggressively. Although many people who work in large U.S. hospitals view infections as either a non-issue or as inevitable, hospitals are beginning to take more severe measures to curb them.

As described in the July 27th, 2007 issue of the New York TImes, three state legislatures have passed bills requiring hospitals to routinely test high-risk patients. The article also notes that that CDC projections estimate that one out of 22 patients would become infected while hospitalized, and that some European countries have had success in aggressively fighting infections.

This is a late response to a problem that has existed for a long time, as an earlier Times article documented on the Veterans Affairs website indicates.

Infection is often caused by carelessness about hygiene, and can lead to tragedy—for instance, the article refers to a woman who lost her mother because of an infection that was probably contracted because a caregiver had unwashed hands. Patients ought to be aware of this issue. If possible, it is a good idea to seek out hospitals where some anti-infection measures are taken.

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The July 24th, 2007 issue of the New York Times Health Section discusses recent findings indicating that a lower nurse-to-patient ratio leads to more patients on respirators getting pneumonia.

One of the Swiss researchers who performed the study (involving 936 patients) said that with fewer nurses, each nurse has a larger workload to shoulder and therefore has less ability to properly follow al