Saturday, November 27, 2010

Patience and Patients Safety.

I was reading my local newspaper and found a columnist discussing an article on Patient Safety and Hospital Error.  We can no longer be surprised that the things we do have become front and center in the cross-hairs of the media.  We have brought this on ourselves.  

The column reported on an article in a recent edition of the New England Journal of Medicine (how scary is it that a local paper columnist is reading articles in the NEJM!), which looked at the rates of “preventable harms” in 10 hospitals after 5 years of active process (2002 – 2007).  While there was a reduction (approximately 1% per 1000 patient days) the reduction was not statistically different, nor (my opinion) clinically significant, even if it was real.  This was true for each category from inconvenience to death.  This was despite active engagement in national and state patient safety training programs. The analysis was done by thorough and fair methodology with internal and external reviewers and appropriate reviewer comparisons.
The authors commented that harm from medical care remains high despite all the programs and the money being spent.  
 The study confirms reports from across the US and Europe about how little progress is being made.  The amount of evidence-based error reduction practices implemented so far has been modest.  All the things that can be done, including substantial improvement on handwashing (!), have not be implemented with any consistency or success.

A few thoughts. 
Systemic and personal behavior does not appear to be easy to change.  While there are folks within health care who are motivated for change, they are not having a lot of success, when measured by outcome.  Most of the money being spent on patient safety teams, training seminars, poster displays, and conferences is being wasted (unless your personal income comes from being on a team or charging for putting on training seminars).  Change is not happening.

My concern is that if healthcare management and healthcare unions wanted change, then change would happen.  I could suggest that there are other vested interests at play, but that would be unfair.  But if neither altruism nor fear of malpractice litigation is insufficient to drive change, then what does it take?
At some point the media will care enough and the public will care enough and the politicians will care enough and we will end up with a healthcare version of the Transport Security Administration and we will have our own version of an intrusive airport pat-down.  And folks will say, well it may not be fun, but it makes our lives more secure.  
For example, the regulators, and legislators always have lots of options, like perhaps a variation on pay-for-performance.  Rather than institutions getting a reimbursement bonus for good deeds, every year that they miss their goals, they lose 1%.  And insurance providers can start jacking up institution protection rates.  

“They” say that carrots work better than sticks, but sticks work.

From my vantage point, hopefully medical laboratories might be having some more success in error reduction because as much as we are a complex distributed activity, our activities are more focussed than hospital admissions.  Some centers have demonstrated some levels of reduced error, at least on a short term basis.  But we need to have an institution perform the longer term year-over-year study like the one above to observe if trends can be seen as improving.  I suspect that most are afraid to look.   

The media already cares, and the public is become more aware.  
Strike 2.


PS.: The article is “Temporal Trends in Rates of Patient Harm Resulting from Medical Care” by CP Landrigan et al.  N Engl J Med 2010;363:2124-34.

1 comment:

  1. Micheal I'm interested in your observations about overall healthcare progress towards error reduction. I think in New Zealand the observations would be similar. Error formation is a complex process mostly about behaviour. Systems require compliance and western culture values individuality and choice so compliance with systems becomes difficult. Forcing functions within systems are a way of achieving compliance. I note your carrot and stick quote and concur. We have just experienced carrot failure with an important intervention and so the stick has come out and seems to be working.


    Don Mikkelsen


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