Reducing medical errors will require better reporting tools, engaged patients and – you guessed it – culture change


Reprinted with permission from MedCityNews

“Culture change.” Those words just keep coming up again and again in talk about what’s needed to reduce healthcare costs, to make better use of health information technology, and in this case to stop preventable medical errors that harm patients.

Patient Safety America founder John James recently published a study in the Journal of Patient Safety that estimated the annual number of medical errors in U.S. at up to four times the number the Institute of Medicine estimated in 1999. He joined other experts representing vendors, providers and pharmacists on Thursday for a TEDMED Great Challenges Google+ hangout focused on eliminating medial errors.

Conversation about how and why he compiled the report was a jump-off point for some specific ideas around how physicians, vendors and patients can incite culture change.

Better reporting tools

Hospitals currently use something called the IHI Global Trigger Tool to flag and measure adverse events. Dr. Michael Victoroff, a family physician and risk management consultant, said hospitals shouldn’t just be collecting data on errors but looking deeper into the kinds and causes of errors that are happening. That could be especially useful for identifying places that have figured out how to prevent a particular type of error.

Ana Hincapie, an assistant professor of clinical sciences at California Northstate University College of Pharmacy, noted that there are many medical errors that happen outside of the hospital setting, such as at the pharmacy, that aren’t being accounted for. Victoroff added that a lot of great data on medical errors is being captured in the form of lawsuits and complaints, but attorneys and hospitals keep that data private.

Include patients in reporting

One idea thrown out was the inclusion of patient input in determining medical errors. Perhaps, for example, in the same way that hospitals administer patient satisfaction surveys, what if someone develops a standard survey instrument that patients were expected to complete after visiting a provider? Or, better yet, what if patients were prompted to review their medical records after every visit, to ensure that what’s been recorded accurately reflects the care they received?

“When patients have access to their own records, they start looking at what’s in there,” said Victoroff. “They become one of the main safety tools for the entire system. They’re the only ones in many instances that can reconcile the accuracy of their record with the truth.”

James chimed in that sometimes, though, it takes years for diagnostic errors to be uncovered. “There are things that you don’t realize about your care until it’s put in perspective,” he said. That implies the need for a long-term strategy for incorporating patient feedback into medical record keeping.

Foster a culture that values patient education

Physicians have limited time to spend with patients, but that doesn’t mean they have to skimp on education. James suggested that providers stay efficient by keeping on hand a set of prepared videos that objectively explain complex topics that doctors often have to explain to patients, and usually do so with a certain bias. That might include things like next steps for a patient with an elevated PSA level, or guidance for a patient who’s debating breast cancer screening.

“Some of these standard things that patients don’t understand the nuances of very well I think need to be put into a video format and actually the doctor doesn’t need to be there,” he said. “He tells his patient, go watch this and come back to me with your questions. There are no bright, clear answers here.”

Victoroff agreed and took that idea a step further. “The internet is the most powerful tool ever invented to help patients collaborate with doctors and care systems,” he said. “It only takes me 10 minutes on the internet to find downloads, guidelines, checklists, questions to ask your doctor, video, and also very valuable blogs and patient comments from people who have had the same thing or similar […] All (administrators) have to do is point patients in the direction of it and give patients a little guidance on how to filter out the nonsense.”

Foster a culture that values active prevention of errors

In his own practice, Victoroff offered a $50 reward to anyone who caught him about to “do something terrible,” he said. Hospitals should convey encouragement to employees to speak up if they see something suspicious.

Push industry players to do their part

John Cox co-founded a health IT company focused on patient-physician communication called Visible Health. He said that in talking to pharmaceutical and medical device companies, he’s been encouraged by their increasing desire to bake patient safety initiatives into the products and services that they offer. For example, a pharma company wants to develop a mobile tool to make patients more aware of the clinical protocols around a condition. “I think there’s a great opportunity for them to be leaders because they do have the economic capabilities to do so,” he said.

A live online event: How can patients help track medical errors?

Why is it so difficult to assess the number of patients that are harmed by medical care errors in hospitals?  And what can patients do to help make sure potentially harmful incidents are accurately reported?

shutterstock_2833913A report published this month in the Journal of Patient Safety says that mistakes contribute to the deaths of some 440,000 hospital patients each year – roughly two to four times as many as previous estimates. Why the wide variance?  As Marshall Allen of ProPublica reported via the NPR Shots blog, a number of studies have given vastly different numbers of fatality rates, including the Institute of Medicine’s (IOM) oft-quoted 1999 report, “To Err is Human.”

John T. James, PhD, a toxicologist at NASA,  compiled numbers for the new study using a weighted average of four reports, including the IOM’s, and according to the Global Trigger Tool, a method of reviewing medical records. That total pointed to a lower limit of 210,000, but James theorizes that life-shortening errors of omission due to failure to follow medical guidelines, as well as diagnostic failures, are under reported. The real number of fatalities, he says, is more than twice that, comprising about one-sixth of all deaths each year in the U.S.

James wrote a book, “A Sea of Broken Hearts,” after the death of his son, which he claims is the result of preventable errors by a cardiologist unit. He also founded an advocacy group called Patient Safety America.  The biggest reason for under reporting at an organization level, he maintains, is “the pride of not being willing to admit an error. Others are failure to recognize any error occurred and fear that your colleagues will know about your error,” he says.

While all parties would like to eliminate errors, James writes in the report, reducing medical errors in our complex and fragmented medical system can only be done with the help of patients, who are constants in this equation. As he says in the study:

All evidence points to the need for much more patient involvement in identifying harmful events and participating in rigorous follow-up investigations to identify root causes.Even for those harms identified in the medical records of Medicare patients, only 14% become part of the hospital’s incident reporting system.

He acknowledges that without a system overhaul, though, that will be difficult. “[Patients] may assume that harm is part of trying to get medical care. They may not know how to report errors or they may fear the confrontation that could be involved. I can tell you personally that loss of a child from medical errors leaves you devastated physically and emotionally. A survivor may simply not have the emotional reserve to deal with the system that, in my opinion, does a great job of protecting the one who made the error,” he says.

John James will be our featured guest in a live online conversation tomorrow as we explore the issues surrounding medical errors reporting. Marshall Allen (@Marshall_Allen), who reports often on patient safety issues, will moderate the group. Ask questions via Twitter using #GreatChallenges, and we’ll answer as many as we can on air. Click here to sign up.


Marshall Allen, Reporter, ProPublica and the ProPublica Patient Harm Community

John T. James, PhD, Chief Scientist of Space Toxicology, NASA Johnson Space Center

John Cox, Co-Founder, President and Chief Executive Officer, Visible Health, Inc.

Ana Hincapie, PhD, Assistant Professor of Clinical Sciences, California Northstate University College of Pharmacy

Michael Victoroff, MD, Executive Vice President and Chief Medical Officer, Lynxcare

Examined Lives: The tale of the bungled biopsy

By Margaret Brunner*

In December, I went to Starsen Radiology* for my annual mammogram. They called me at the end of the month. They said I needed to come back immediately for another mammogram because they had found a suspicious mass in my right breast. So I went in that day for another mammo. They definitely saw something, and said I needed to get a biopsy done ASAP, and could perform it, f I wanted.

Of course, I panicked.  I called my Ob-Gyn to see what she had to say. The Gyn office said that Starsen* did biopsies all the time, and that it would be okay to schedule it with them. I called and set the appointment for January 7th. I’ll never forget the date.

The big day arrived and I went to Starsen for the biopsy.  I was nervous as heck. I’d never had this done before, so I didn’t know what to expect.  There were two nurses there to help me prep. Then the doctor came in to explain the procedure and had me sign a paper, of course.

The procedure, called stereotactic biopsy, was pretty painful – they said there would be “some discomfort.” They gave me a local anesthetic, but it was never enough.  Boy, was I glad when it was over.  They told me that they would send the tissue sample to the pathology department in a local hospital and that it would take about one to two days to get the results back.

The waiting was the worst part.  You start to think about horrible possibilities.  Starsen never gave me an idea of how many biopsies show a malignancy, though I did find out from another breast center that 80% turn out to be benign. I’ve been relatively healthy all my life.  So, when I got the call that I would need a biopsy, I was very worried. I kept on thinking, “What if do have breast cancer?  How am I going to tell my kids? I haven’t done so many things that I still would like to do.”

This then led me to develop hives, which happens when I’m psychologically stressed.  On day two, I called Starsen to see if they had the pathology report. Nothing yet.  Day three, still nothing.  Day four, nothing.  Day five, nothing.  Imagine my fears growing and my hives getting worse.  Day six: Starsen had finally gotten the pathology report back. It was benign!  Hallelujah!  I was so happy.

Fast forward to a week later. I get a call from Starsen, who tell me that they took a sample of the wrong area.  Are you kidding?? I couldn’t believe it.  When they mentioned risks before the procedure, they mentioned infection. They did say they might not get the right sample, but that it was very unlikely. Not only did I have to endure the pain of the procedure and many days of waiting for the pathology report, I now found out that they got the wrong area. I never found out why, and another radiologist told me the news – not the one who had done the procedure. They tried to make me go to them for another biopsy.  I declined.  I didn’t pay anything for that procedure out of my pocket – I guess insurance picked up the tab.

I wasn’t sure what I should do.  Should I see a surgeon?  I got a few names in my area. Then I talked to someone in my town and found out about a breast surgeon in Manhattan. Apparently, many women in this area have gone to see her and she is well regarded in the field. I wanted to see someone who really knew about breast issues.  I finally got to see her on February 6th.  Because the mass was so far back in the breast, she recommended another stereotactic biopsy, instead of surgically getting a sample of the suspicious mass.  But she said she wanted the radiologists at her location do the biopsy. That was fine with me.  I loved the breast surgeon.  She was a kind doctor.

On February 12th, I went in for my biopsy.  What a different experience.  There were two nurses there for my procedure, but they really “held my hand” to tell me what was going on and what they needed to do during the procedure.  I really liked that aspect.  I also got to meet the two radiologists who were working on my case.  They introduced themselves to me beforehand and told me what to expect during the procedure.  And they gave me their phone number in case I had questions.

After the procedure, the radiologist got another image to make sure they got the right area. The radiologist in New Jersey hadn’t bothered with that.  I loved the radiologist who performed the biopsy.  She kept asking how I was feeling. Although she gave me a lot of lidocaine, I still felt quite a painful tug and pull during the process.

They sent the sample to their pathology group and said to expect the report within 24-48 hours.  After my last experience, I was very skeptical about getting it that soon.  I was ready to wait six days again.  But boy, was I wrong.  The pathology report came back incredibly quickly – 24 hours!  And happily, it was benign!

If I had to do it over again, I would have found a doctor that other women have seen and speak highly of.  I would asked my friends right away to see if they knew of a good doctor.  Telling my friends also helped relieve the stress of worrying about whether I had cancer. My friends are truly one my pillars of strength.

*Names have been changed to protect privacy.

Visit TEDMED’s Great Challenges website to discuss how to eliminate medical errors.

Great Challenges live events double-header: Teams of experts discuss medical innovation, preventing errors in healthcare

TEDMED held two live events yesterday with team leaders from the Great Challenges program.

The first, achieving medical innovation, centered on affordability, oft cited as a barrier to getting new products and services to market, particularly technology.  Participants quickly countered the notion by pointing out how often innovation is introduced to save money — and how small, cost-efficient steps can make a big difference.  Watch the group here:

For more on this event, see the Twitter recap by MedCityNews, “TEDMED innovation panel: We’re on the verge of a patient engagement explosion.”

A second group met later in the afternoon to talk out the more sobering topic of medical errors. Here, too, the topic of where and how to innovate, and particularly when technology helps or harms, figured large in the conversation, as well as introducing novel collaboration.  In this case, however, the group agreed that the system must first cure itself before asking further involvement from patients in their own care.

John Nosta, EVP of Ogilvy CommonHealth, moderated the events.  The program is sponsored by Robert Wood Johnson Foundation.  See TEDMED’s Google Plus page for upcoming Hangouts, which will be held almost ever week through February.

Health’s Great Challenges are hot topics this week

At TEDMED 2012, conference Delegates and TEDMED Live attendees voted to choose the top 20 Great Challenges, the most pressing, pervasive and complex issues the nation is grappling with in health and medicine. They chose well, apparently. Conversation on many of the Challenges — the goal of the program — was lively both among the TEDMED community at at large, including features on blogs and in major news media.

David Mayer, MD, vice president of Quality and Safety for MedStar Health, wrote about Challenge #5, Eliminating Medical Errors, on his blog, “as this is a problem that persists despite the hard work of many of us who have dedicated our careers trying to prevent,” he writes. Educating students and residents is critical to reducing error, he says, not only to hit the ground running with good training, but in offering fresh perspectives on the issue. A contributor, Kare Anderson, made waves with the piece, How Hospitals Can Stop Killing So Many Patients. Medical errors are the third leading cause of death in the country, she cites, and suggests that patients demand accountability and transparency, and then do as much comparison shopping as possible before selecting a hospital. We’ve heard it before: We spend more time shopping for a television than for a doctor, even though the stakes are, of course, incalculably higher.

End-of-life Care, Challenge #3, garnered much attention thanks to an op-ed by Bill Keller in The New York Times, “How to Die.” Keller wrote about an in-hospital hospice protocol in the U.K. that offer an alternative to the sometimes invasive and painful, and often fruitless measures, that accompany our last days here in the U.S. End-of-life care is a huge cost issue, Keller writes:

“….a quarter or more of Medicare costs are incurred in the last year of life, which suggests that we are squandering a fortune to buy a few weeks or months of a life spent hooked to machinery and consumed by fear and discomfort.”

Yet we should approach dying with dignity more out of concerts for the patient and his or her family, he says — a kinder way of death — than out of fiscal prudence, which will ultimately make palliative care more popular and culturally acceptable for the American public as well. On a brighter note, TEDMED’s new consulting clinical editor Pritpal Tamber, M.D., director of Optimising Clinical Knowledge — which helps organizations implement established clinical know-how — wrote on his blog wrote about what’s needed on all fronts to manage these daunting hurdles we face:  an inspiration immersion, leading to a badly needed healthcare reinvention.  Welcome, Pritpal!

Can we eliminate medical errors?

All humans make mistakes. Doctors and nurses are human; they make mistakes. All systems are imperfect. Medical professionals use systems.

Errors by medical professionals and systems are inevitable (unfortunately, they send 2.4 million patients to hospitals yearly and are directly linked to 200,000 annual fatalities). Regardless of methods used to detect, prove and compensate for medical errors, how much better can we do in reducing or eliminating medical errors and what areas should we focus on to get the best improvements?

TEDMED’s Great Challenges program is a forum to discuss pervasive, broad-based issues like these that demand collective understanding and action to manage. Join the online community to share your thoughts and to ask questions directly of experts on the issue.