Showing posts with label Errors. Show all posts
Showing posts with label Errors. Show all posts

Wednesday, June 25, 2014

1 in 5 elderly U.S. patients injured by medical care (or not)

A recent paper in BMJ Injury Prevention found that almost 19% of Medicare beneficiaries suffered serious adverse medical events (AMEs), 62% of which occurred from outpatient claims. Not surprisingly, poorer health, more comorbidities, and impaired activities of daily living were associated with higher risk.

Over 12,500 patients were surveyed and their Medicare claims were analyzed. Nearly 80% of patients who did not experience an AME survived to the end of the study compared to 55% of those who had AMEs. Statistical significance was not mentioned, and confidence intervals and p values were not stated.

The authors concluded that AMEs should be avoided because of the excess mortality and costs.

It is hard to argue with that, but as is true of many papers like this, the terminology changed in the body of the paper. An article about it quoted the lead author, a gerontologist, as saying, "These injuries are caused by the medical care or management rather than any underlying disease." Thus, AMEs became "injuries."

In the methods section, the authors list all of the ICD-9-CM codes included in the study.

Some of the codes are clearly preventable medical errors such as 997.02 Iatrogenic cerebrovascular infarction or hemorrhage, 998.2 Accidental puncture or laceration during a procedure, not elsewhere classified, 998.4 Foreign body accidentally left during a procedure, 998.7 Acute reaction to foreign substance accidentally left during a procedure, and the codes E870-867 "misadventures."

However, many may or may not be preventable like 997.1 Cardiac complications, not elsewhere classified, 997.31 Ventilator associated pneumonia, 997.41 Retained cholelithiasis following cholecystectomy, 998.00 Postoperative shock, unspecified, 998.30 Disruption of wound, unspecified, 998.5 Postoperative infection not elsewhere classified, and 998.83 Non-healing surgical wound.

A series of codes, E930–E949, comprises adverse drug events, most of which are not preventable.

The numbers of patients with each specific complication were not provided.

This did not stop medical news media from proclaiming more doom and gloom.

HealthDay: "1 in 5 Elderly U.S. Patients Injured by Medical Care"
WebMD: "1 in 5 elderly patients injured by medical care"
Today Topics: "Medical injuries affect almost one in five older adults in receipt of Medicare"

It is impossible to conclude from the data that all of these AMEs were caused by "medical care or management." You can quibble about whether some complications are preventable or not, but the percentage of preventable AMEs is far less than 19%.

And how many more deaths would have occurred had the patients not been subjected to "medical care or management"?

I wish people would stop writing these kinds of papers and ease off on the sensationalist reporting of them. But I guess if they did, I would have less to write about.

Tuesday, February 25, 2014

"Medical errors kill hundreds of thousands each year in the US"

How about that headline?

It appeared on, "the first Russian 24/7 English-language news channel which brings the Russian view on global news."

The story, which originally ran in November of 2013, was resurrected again on Twitter yesterday. It's subject was a paper that claimed as many as 440,000 patients die from medical errors in the United States every year.

Back in September, I criticized the study because it assumed that every death was both preventable and caused by a medical error. Neither assumption is correct. It also extrapolated the doomsday figures from only four other papers describing just 38 deaths.

In that post I said, "Inflating the incidence of these problems does nothing but further erode the already shaky confidence of the public in the medical profession. And creating the impression that such events are totally preventable leads to unrealistic expectations and unachievable goals."

So why am I bringing this up again?

Take a look at a few of the comments from the story [printed verbatim]:

Old news, as many as a million die each year cause of doctor errors. Thats why their malpractice insurance is so high. Legal unintentional homicide.

It's convenient to claim such deaths are errors but a great many are deliberate. They know such incidents will not be investigated as crimes. It's very easy to conceal a murder if no one is looking. The medical system is completely corrupt.

if they'd stop getting high in med school and pay more attention maybe this wouldnt happen. then there is their attitudes. Heaven forbid anyone needs medical care, that's for sure.

According to CDC, medical errors is not even a category of death, but they published research that indicates drunk drivers kill about 10,000 yearly. If that is correct, then doctors kill almost twice that many every hour of every day -. MADD should be mad about DEADLY DOCTORS. You are 40 times more likely to be killed by a deadly doc than you are by a drunk driver. And yet - where is the "funding" for this deadly phenomena?

I know those who comment on the Internet usually do not represent the views of rational individuals, but it infuriates the hell out of me that the 440,000 deaths from medical errors estimate, which is clearly wrong, is repeatedly trumpeted all over the place and so readily believed.

By the way, the paper appeared in the Journal of Patient Safety, which recently underwent an editorial change due to a kickback scandal involving former editor Dr. Charles Denham. That's another story (here).

Do doctors and hospitals make mistakes? Yes. Can we improve? Yes. Does it help to exaggerate the magnitude of the problem? Emphatically, no.

Monday, September 23, 2013

Medical errors and deaths: Is the problem getting worse?

Medical errors are a real problem. I won't deny that.

It was bad enough when the often-quoted Institute of Medicine figure that 98,000 deaths per year in the US are caused by medical errors was in vogue, but now a paper in the Journal of Patient Safety states that adverse medical events result in 210,000 to 440,000 deaths per year and 10 to 20 times those numbers of serious harms.

Since the paper disparages the medical profession, it has received a lot of media attention.

Most articles about it simply regurgitate the dismal estimates without any real attempt to dig into the paper's methods.

Let's take a closer look.

As is true of many papers, the abstract is a bit sketchy when describing how the paper arrived at its conclusion.

The full text of the paper reveals the author found four studies that looked at what are described as preventable adverse events in US hospitals within the last seven years. All four used the Global Trigger Tool which involves the screening of records for adverse events by nurses or pharmacists and a secondary review by physicians.

Based on opinions by "experts," the author made a key, but erroneous, assumption that all adverse events are preventable.

The basis of that assumption was apparently this statement in the methods section of a 2011 paper in Health Affairs about the Global Trigger Tool.

"Because of prior work with Trigger Tools and the belief that ultimately all adverse events may be preventable, we did not attempt to evaluate the preventability or ameliorability (whether harm could have been reduced if a different approach had been taken) of these adverse events."

The "belief that ultimately all adverse events may be preventable" is not supported by any facts, which are not necessary I suppose if one simply has a "belief."

Personally, I do not share the belief that all adverse events are preventable. Let me give you a few examples of why.

Aspiration of gastric contents is considered a preventable adverse event, yet I can see no way to prevent every single occurrence of aspiration. If you can, please share it with the rest of us.

Leukopenia [a dangerously low white blood cell count], which often leads to sepsis, and is a common side-effect of cancer chemotherapy could be prevented by never using chemotherapy, but is that a realistic solution?

Repeated studies of deep venous thrombosis have found that no measure, be it drug or mechanical device, is 100% effective in preventing DVTs.

Several papers addressing the use of the Surgical Care Improvement Project guidelines for prevention of surgical site infections after colon surgery have found that even when guideline adherence is nearly perfect, at least 8-10% of patients develop SSIs.

Sometimes adverse events are due to patient-related factors. From an editorial in this month's JAMA Surgery commenting on a paper about SSIs:

"[W]e are left with the yet unanswered question about how to remediate the problem [SSI] beyond adherence to SCIP. Short of a large scale public health campaign to address smoking, obesity, and comorbid disease, the findings do not expose a practical way forward."

Pop quiz.

The Journal of Patient Safety paper estimating 210,000 to 400,000 deaths due to preventable adverse events was based on four papers with a total of how many deaths?

a. 38
b. 380
c. 3,800
d. 38,000
e. 380,000

If you said "c. 3,800," you would have only been wrong by a factor of 100. The correct answer is "a. 38."

Adverse events and deaths due to medical errors are serious issues that need to be addressed. But inflating the incidence of these problems does nothing but further erode the already shaky confidence of the public in the medical profession.

And creating the impression that such events are totally preventable leads to unrealistic expectations and unachievable goals.

Note: Upper range of supposed deaths from medical error corrected from 400,000 to 440,000 on 2/24/14.

Monday, March 18, 2013

Healing the hospital hierarchy: A different view

The other day, Theresa Brown, an oncology nurse who has somehow finagled a quasi-regular column in the New York Times, wrote about, you guessed it, another unpleasant encounter with a mean doctor.

Her patient was about to undergo a stem-cell transplant when he developed what she called "textbook symptoms of a heart attack." A cardiogram had been done and while awaiting the arrival of a cardiologist (apparently a myocardial infarction can only be ruled out by a cardiologist at her hospital), the patient's doctor, a big bad oncologist, arrived on morning rounds.

He took a quick look at the EKG and said “This does not concern me.” In the hallway, Nurse Brown challenged him in front of his team of doctors and he had the temerity to ask her why in an intimidating way. 

After another 600 or so words about collaboration, blah, blah, teamwork, blah, blah, we come to find that the cardiologist confirmed the oncologist's impression that the EKG did not show a heart attack and the patient went for the procedure.

OK, I'm not saying that doctors don't intimidate nurses. And I'm not saying that it's all right to do so. I realize that some physicians can be annoying, overbearing and even disruptive. I just blogged about this myself today on another site. But was this really the best anecdote that Nurse Brown could come up with about how she rose to the defense of a poor patient?

When I was in practice, I had no problem with nurses questioning my actions if the question was based on a legitimate concern and (this is important) the nurse knew what she was talking about.

Unfortunately, the latter feature was often not present in the discussion. This is because as Nurse Brown points out, "Doctors and nurses are trained differently." 

She also says, "Some nurses reject the whole idea of doctor’s orders; they think the term makes nursing sound subservient." Excuse me? What would be the alternative? Nurses deciding what should be done? Anarchy?

Maybe it would have been better if she had said to the oncologist, "Can I have a word with you in private?" 

How do you think a nurse would feel if I confronted him in front of all of his colleagues at the nurses' station? 

Nurse Brown laments that there are no protocols to resolve disagreements between doctors and nurses. I disagree. Since the overwhelming majority of orders are not of a life-or-death nature, one can simply go up the chain of command. When this has happened to me, I have spoken to the nurse's supervisor to help sort things out. It works in reverse too. The nurse can talk to her boss who can talk to the doctor's chief of service. It's called "communication," one of the very things Nurse Brown says is lacking.

One of the reasons so many doctors are depressed and burnt out is the seemingly endless supply of articles like Nurse Brown's blaming us for everything that is wrong with medical care in the United States.

Friday, November 23, 2012

How to operate on the wrong site

Here’s a story that illustrates how to operate on the wrong site. 

In a news article about some sanctions that the State of California imposed on certain hospitals for misdeeds, the following summary of one incident appeared. I have added some emphasis in bold.

A six-year-old boy had to undergo a second surgery to remove a growth after a surgeon performed the wrong surgery on his tongue.

"This failure resulted in [the patient] being exposed to the risks of bleeding and infection, and unnecessary exposure to the risks associated with anesthesia that was needed to perform the right procedure," state documents say.

The surgeon told investigators that he couldn't be sure whether a time-out [explanation: a pause in the preoperative routine to ask all members of the OR team if they all agree on who the patient is and what the operation will be], which was said to have transpired according to the hospital's policies, was ever done.

"Either time-out was not done or it was done, but I could not recall what procedure was said," the surgeon told state investigators. The surgeon then said that team members, who should have known the correct procedure, should have asked why there was no specimen of tissue from the removed growth.

Asked whether he examined the patient prior to the surgery, the surgeon replied, "Usually, I don't examine anybody. In this case, there was no time to do pre-operative visit. From now on, I need to see the patient prior to surgery."

The hospital was fined $50,000.

I can’t blame anyone who read that story for wondering just what the hell we are all doing in hospitals today. 

The wrong operation, a tongue-tie release, was performed. The surgeon couldn’t recall if a time-out was done. He blamed the staff for not mentioning that no specimen was obtained. He apparently had seen the patient in his office but did not re-examine him on the day of surgery and did not usually do so. It’s not all bad though. “From now on,” he will start seeing the patients before he operates. 

The official report cites the hospital for failing to follow its own procedures regarding verification of the type of operation to be performed. 

It is basic good practice and common sense to examine every patient again on the day of surgery and reconfirm the nature of the procedure, the correct side and answer any questions the patient or family might have. For example, I have seen lymph nodes that I was asked to biopsy shrink dramatically in the 10-14 days between my office examination and the planned surgery day.

Who obtained consent from the child’s mother? What did the consent form say? Didn’t the circulating nurse or anyone else look at the form to verify what operation was to be done? Don’t the nurses enforce the time out rule? What was the anesthesiologist doing?

Maybe the fine and the hospital’s “system error” type plan of correction, which entails monitoring 30 time outs per month for an unspecified period of time, will prevent this from happening again.

I doubt it. 

See how easy it is to operate on the wrong site? That’s why people can defeat any system correction plan.

Tuesday, June 12, 2012

CNN makes mistakes reporting "10 shocking medical mistakes"

I am sympathetic to those who champion efforts to improve patient safety and am not against exposing gross errors as examples of what not to do. However, a recent article on the CNN website entitled “10 shocking medical mistakes” suffers from poor reporting.

The article cites anecdotes involving patients with bad outcomes because of medical errors. I am not trying to minimize the fact that people die or are disabled from medical errors, including those mentioned in the CNN piece, but can we get the facts straight?

6. Mistake: Air bubbles in blood
Cause: The hole in a patient's chest isn't sealed airtight after a chest tube is removed.
Consequences: Air bubbles get sucked into the wound and cut off blood supply to the patient's lungs, heart, kidneys and brain. Left uncorrected the patient dies.
Prevention: If you have a chest tube in you, ask how you should be positioned when the line comes out.
Example case: Blake Fought

Simply googling the patient’s name [Blake Fought] yields a number of hits. On the first page is a story that Fought’s tube was really a central venous catheter [not a chest tube] through which he had been receiving nutrition. An inexperienced nurse apparently used improper technique to remove the catheter and an air embolus occurred. Yes, it’s a tragic and preventable mistake and the patient died. But the advice about a chest tube is misleading.

9. Mistake: Lookalike tubes
Cause: A chest tube and a feeding tube can look a lot alike.
Consequences: Medicine meant for the stomach goes into the chest.
Prevention: When you have tubes in you, ask the staff to trace every tube back to the point of origin so the right medicine goes to the right place.
Example case: Alicia Coleman

Googling “Alicia Coleman tube” brings one to the third hit on Google [just below two citations of the CNN account], which is a story from the Omaha World Herald telling of this poor child’s demise from having been given a drug meant for the tube in her stomach via a catheter [not a chest tube] in her jugular vein. The advice about checking where the tube goes is not incorrect, but the reporting is sloppy.

4. Mistake: Fake doctors
Cause: Con artists pretend to be doctors.
Consequences: Medical treatments backfire. Instead of getting better, patients get sicker.
Prevention: Confirm online that your physician is licensed.
Example case: Sarafina Gerling

How does this qualify as a “mistake”?

5. Mistake: The ER waiting game
Cause: Emergency rooms get backed up when overcrowded hospitals don't have enough beds.
Consequences: Patients get sicker while waiting for care.
Prevention: Doctors listen to other doctors, so on your way to the hospital call your physician and ask them to call the emergency room.
Example case: Malyia Jeffers

A crowded ER is not a “mistake,” nor is it shocking. It’s an everyday occurrence. Calling your doctor will not alleviate crowding unless your doctor decides to see you herself. That will at least keep you from making the crowding worse. Don’t use the ER for non-urgent or chronic problems. ER patients are not seen on a “first come, first served” basis. The sickest patients are seen first. Stories [one of which appeared on the CNN website in 2011] about Malyia Jeffers describe waiting but more importantly what appears to be human error in recognizing severe sepsis on the part of the ER triage nurse.

Many of my Twitter followers picked up on the above problems with the CNN article. Reasoned discourse about medical errors can help us all try to prevent them. This sort of story diverts our attention from the real issues. 

Maybe CNN should ask a doctor, or at least a fact checker, to vet articles such as this.