Tag: Bob Wachter

Why diagnostic errors don’t get any respect and what can be done about it

Jun 2, 2008• 3

By Bob Wachter

I gave a keynote yesterday to the first-ever meeting on "Diagnostic Error in Medicine." I hope the confab helps put diagnostic errors on the safety map. But, as Ricky Ricardo said, the experts and advocates in the audience have some ‘splainin’ to do.

I date the origin of the patient safety field to the publication of the IOM report on medical errors (To Err is Human). It is the field’s equivalent of the Birth of Christ (as in, there was before, and there is after). But from the get-go, diagnostic errors were the ugly stepchild of the safety family. I searched the text of To Err… and found that the term “medication errors” is mentioned 70 times, while “diagnostic errors” appears twice. This is interesting because diagnostic errors comprised 17 percent of the adverse events in the Harvard Medical Practice Study (from which the IOM’s 44,000 to 98,000 deaths numbers were drawn), and account for twice as many malpractice suits as medication errors.

What I call “Diagnostic Errors Exceptionalism” has persisted ever since. Think about the patient safety issues that are on today’s public radar screen (i.e., they are subject to public reporting, included in “no pay for errors,” examined during Joint Commission visits, etc.). It’s a pretty diverse group, including medication mistakes, falls, decubitus ulcers, wrong-site surgery, and hospital-acquired infections. But not diagnostic errors. Funny, huh?

There are lots of reasons for this. Here are just a few:

The Technology Hype Cycle: Why bad things happen to good technologies

May 19, 2008• 4

By Robert Wachter

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Fresh on the heels of my recent bar coding epiphany comes another “unintended consequences” article. It turns out that the whipsawing that accompanies the adoption of new technologies is completely foreseeable, the “Why doesn’t this thing work right?” phase is as predictable as the seasons.

Thanks to Dr. Mark Wheeler, Director of Clinical Informatics of PeaceHealth, for introducing me last week to the “Technology Hype Cycle” concept. The Cycle, originally described by the IT consulting firm Gartner, is comprised of an all-but-inevitable series of phases that technologies tend to traverse after they are introduced. The five phases are:

Technology Trigger – The initial launch; a new technology reaches public or press attention.

Peak of Inflated Expectations – A few successful applications of the technology (often by highly selected individuals or organizations) help catalyze unrealistic expectations, often aided and abetted by hype driven by word of mouth, the blogosphere, or vendor spin.

Trough of Disillusionment – Virtually no technology can live up to its initial PR. As negative experience mounts, the balloon is pricked and air rushes out. The press moves on to cover another “hotter” technology, like a moth flitting to the light (see Phase II).

Slope of Enlightenment – A few hardy individuals and organizations, seeing the technology’s true potential, begin experimenting with it unencumbered by inflated expectations. Assuming that the technology is worthwhile, they begin to see and demonstrate its value.

Plateau of Productivity – As more organizations ascend the “Slope of Enlightenment,” the benefits of the technology (which by now has improved from its initial clunky phase) become widely demonstrated and accepted. The height of the plateau, of course, depends on the quality of the technology and the size of its market.

Should Patient Satisfaction Scores Be Adjusted for Where Patients Shop?

Apr 15, 2008• 5

By Robert Wachter

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Last week, Medicare added patient satisfaction data to its hospital reporting website. This is progress, but it raises an interesting question: should patient satisfaction scores be case-mix adjusted?

The
motivation to include patient satisfaction data comes from the
Institute of Medicine’s inclusion of “patient-centeredness” as one key component of quality.
And what could be simpler than asking patients a few questions, as the
Center for Medicare & Medicaid Services (CMS) survey does. (A pdf
of the survey, formally known as HCAHPS, or “H-CAPS”, for Hospital
Consumer Assessment of Healthcare Providers and Systems, is here).
I like the addition of the patient experience data and found the
presentation on the CMS site to be fairly reader-friendly (as did US News & World Report’s
Avery Comarow). For example, it only took a few seconds to find my
hospital’s performance on the summary question, “Would you definitely
recommend this hospital?”:

UCSF Medical Center: 80% yesAverage for Northern and Central California: 65% yesAverage for all U.S. Hospitals: 67% yes

[You’ll note that we didn’t do too badly. But it would be legitimate to
wonder whether I, being relatively fond of my job and unenthusiastic
about being shunned by my colleagues, would have shown you something
that made us look crummy. You should have the same skepticism when you
look at every hospital’s web site, a point Peter Pronovost, Marlene
Miller, and I made in this JAMA article.]

Average Time of Discharge: Why a Hospital is Not a Hilton

Mar 26, 2008• 7

By Robert Wachter

Do you get as annoyed as I do about being pressured on your “Time of Discharge?” I just received my monthly report, and we’re in The Doghouse again: our average TOD – 3:28 pm – is hours after “check-out time.”

But when did we turn into the Holiday Inn?
Robert_wachter

Let’s start by appreciating where this comes from. Many hospitals, including mine, tend to run full – given the huge fixed costs of operating a modern hospital, being full is probably the only way you can be profitable, just like the airlines. Queuing theory (don’t tell me you’ve forgotten your queuing theory!) tells us that, when you’re full, you should look for fundamental choke points and do your best to relieve them. There are PhDs working for McDonald’s whose lives are dedicated to figuring out how to avoid lines at lunchtime rush hour, and others working in aviation who model the best ways to load passengers onto planes (latest answer courtesy of a Fermi Lab astrophysicist: start in the back and load every third row, back to front, sequentially).

The main stenosis in hospitals occurs in the early afternoon: the morning’s OR cases are finishing, the ED is heating up, the clinics are sending over elective and urgent admissions, the respiratory therapists have done their weaning and “liberated” a few patients from vents… and everybody needs a floor bed. Now! But they’re all taken, since nobody’s gone home yet.

Gridlock. Bad for business.

How do you fix this? About a decade ago, some smart consultant (I can’t figure out who, but he or she must have had a terrific PowerPoint slide making this point since every hospital I know of picked up on it) came up with the solution: let’s measure and report the time of discharge by service, shining the holy light of transparency on service chiefs like me to get them cracking. And since everybody likes Goals, how about we set a guideline – “The Discharge Time on 5 South is 11 am” – and post it in every room and nurse’s station. Then it won’t be a shocker to the patients when we try to hustle grandma into the wheelchair and roll her out of her room before noon.

Creating a Facebook-like medical record

Jan 11, 2008• 30

By Bob Wachter Robert_wachter

The explosive growth of Facebook and MySpace illustrates the market for electronic tools to enhance communication and collaboration. Could there possibly be another workplace more in need of social networking tools than the modern hospital?

If you are not familiar with Facebook, find yourself a teenager and take a look over his shoulder while he is using it (mine are available for rent if you get desperate; the best time to catch them is when they should be doing homework). In one thrilling, chaotic electronic e-universe, the site allows users to exchange instant messages with dozens of friends, to post pictures and videos, and to link to virtually everything on the Web – all at the same time. John McCain would be flabbergasted.

Look at How Safe [Fill in the Blank] Is by Bob Wachter

Dec 29, 2007• 2

But is it as simple as that really? Perhaps not. In the commentary that follows, Bob Wachter has a very different take on the airline analogy. Analogies are useful things, true, he argues. But perhaps not as useful as the cure-healthcare-by-adopting-model-posed-by- [ insert industry / EU member state here ] might have us believe. Who should you believe? That’s up to you. You’ll find more of Bob’s excellent commentary on quality and patient safety in the THCB archives and on his blog, Wachter’s World.

The rate of fatal domestic airline crashes has fallen by 65% in the past decade – from an amazingly low rate of one fatal accident in about 2 million departures in 1997, to a breathtakingly low rate of one in 4.5 million departures this year. Flying just keeps getting safer and safer.

Beginning with the 1999 Institute of Medicine report on medical errors, aviation has become the poster child for patient safety. In fact, it was an aviation analogy – the translation of the 44,000-98,000 deaths per year from medical errors into “the equivalent of a jumbo jet a day crashing” – that jumpstarted the patient safety field in the first place.

On the whole, I like the aviation analogy, because it energizes us and helps illustrate the need for certain safety-oriented practices, such as standardization, simplification, simulation, teamwork training, and effective reporting systems and regulations. It is also uniquely accessible: who would ever fly electively if a big plane went down every day in the U.S.? Yet hundreds of thousands of people check into hospitals and clinics electively daily.

But lately, I’ve sensed gathering pushback against the aviation analogy – as well as against analogies from other industries. “This has nothing to do with us,” I hear from colleagues sometimes. “Healthcare is so different.” And they’re partly right. For example, we have learned that dampening down authority gradients on a med-surg ward is orders of magnitude harder than doing so in a cockpit. Here’s why: to prevent another Tenerife disaster (the horrific 1977 runway incursion/collision of two 747s, ostensibly caused when the flight engineer – who suspected there was a large airplane blocking the way – felt uncomfortable speaking up to his boss, the pilot), aviation had to transform its culture.

Rating Doctors Like Restaurants, by Bob Wachter

Dec 4, 2007• 19

Robert Wachter is widely regarded as a leading figure in the modern
patient safety
movement. Together with Dr. Lee Goldman, he coined the
term "hospitalist" in an influential 1996 essay in The New England
Journal of Medicine. His most recent book, Understanding Patient
Safety, (McGraw-Hill, 2008) examines the factors that have contributed
to what is often described as "an epidemic" facing American hospitals.
His posts appear semi-regularly on THCB and on his own blog "Wachter’s World."

So Zagat will now be rating doctors, using the methods it perfected helping you find the best sushi in Brooklyn Heights. What’s next, Consumer Reports rating grad schools? Fodor rating auto mechanics?

Whatever you think of Zagat’s cross-dressing, it again demonstrates
the bottomless market for doctor rankings. HealthGrades, the Colorado
company that breathlessly delivers its “200,000 Americans died from
medical errors in 200X!” pronouncements every year (grabbing a bunch of headlines, despite the fact that this report is based on measures that were not intended for this purpose and really aren’t measuring deaths from errors), appears to be doing quite well,
thank you, largely fueled by its doctor ratings. And every metropolis’s
city magazine has its “[Your City’s Name Goes Here]’s Best Doctors”
issue, based almost entirely on peer surveys. Most docs scoff at these
ratings (particularly docs like me who haven’t made their city’s list),
but they clearly move magazines. [I’ll discuss hospital rankings,
especially US News & World Report’s Best Hospitals list, in a future posting.]

HOSPITALS: Dennis Quaid’s Kids – Are VIPs Safer? By Bob Wachter

Nov 26, 2007• 6

Robert_wachter Robert Wachter is widely regarded as a leading figure in the modern patient safety movement. Together with Dr. Robert Goldman, he coined the term "hospitalist" in an 1996 essay in The New England Journal of Medicine. His most recent book, Understanding Patient Safety, (McGraw-Hill, 2008) examines the factors that have contributed to what is often described as "an epidemic" facing American hospitals. His posts appear semi-regularly on THCB and on his own blog "Wachter’s World."
The Entertainment Blogosphere was atwitter this week with the story
of actor Dennis Quaid’s twin
newborns, who reportedly received a
1000-fold heparin overdose at Cedars-Sinai Medical Center in La La
Land. Cedars’ Chief Medical Officer Michael Langberg may win this
year’s Oscar for fastest public apology – having learned the lesson
from the 2003 Duke transplant error, where the hospital stonewalled for a week or so, adding chum to the media feeding frenzy.

The
error came during heparin line flushes, when a 10,000 units/ml solution
of heparin was mistakenly substituted for the intended 10 units/ml
solution. Although the cases required pharmacologic reversal of the
anticoagulant effect, thankfully there were no bleeding complications.

These cases come on the heels of last week’s report
out of Dallas that the state-supported UT-Southwestern kept an “A-list”
of potential donors and assorted bigwigs. Apparently, when these folks
come to the hospital or clinic, they may get a personal greeting, a
preferential parking spot, perhaps even an escort to their appointment.
My friends at Health Care Renewal, who chronicle and condemn healthcare’s corporate influences, were shocked. Shocked!

I’m
not. Every hospital I know keeps some sort of a VIP list, a tripwire to
alert the organization of the arrival of a dignitary or billionaire.
Even when there isn’t a formal list, you can be sure that a single call
to the CEO’s office is more than enough to lift the velvet rope. That’s
a simple fact of life, and to me not worthy of a big fuss.

When is a Medical Error a Crime? by Bob Wachter

Nov 16, 2007• 17

Bob Wachter is one of the nation’s leading experts on medical safety and one of the pioneers of the hospitalist movement. And now he’s descending into the mire of blogging! So we’re pleased to cross post one of the more recent pieces from his (relatively) new blog Wachter’s World.

Robert_wachter The first commandment of the modern patient safety movement was “Thou Shalt Not Blame.”
Old-Think:
errors are screw-ups by “bad apples,” and can only be prevented by some
combination of shaming and suing the doctor or nurse holding the
smoking gun. New-Think: errors represent “system problems;” any
attempt to assess blame will drive providers underground, inhibiting
the free-flow of information so crucial to error prevention. Like
most complicated issues in life, the truth lives somewhere between
these polar views. In the main, the “no blame” view is right – most
errors are committed by good, hardworking docs and nurses, and
finger-pointing simply distracts us from the systems fixes that can
prevent the next fallible human being from killing someone.Yet,
taken to extremes, the no blame argument has always struck me as both
naive and more than a little PC. Anyone who has practiced for more than
a month can name docs and nurses who they would never want caring for
their loved ones. And what about the substance-abusing nurse, the
internist who doesn’t keep up with the literature, the
retractor-throwing surgeon, or the provider who refuses to follow
reasonable safety rules. If nobody is ever to blame, who is
accountable?