11 ms·

How to stop hospitals from killing us

153 points by bmahmood 14y ago

nancyhua 14y ago
I feel sorry for everyone involved in this complex industry, no arena of which is aligned with the goal of people's long term health. The common sense suggestions in this article are a good step towards improving things by increasing transparency and accountability via documentation but may not address the root problems.
greenyoda 14y ago
"A few years ago, Long Island's North Shore University Hospital had a dismal compliance rate with hand washing—under 10%. After installing cameras at hand-washing stations, compliance rose to over 90% and stayed there." There's something seriously wrong with the medical profession if doctors only wash their hands 90% of the time, even if they know they're being watched. The words "reckless disregard for human life" spring to mind. How many deaths from infections per year could be prevented if hospitals just fired any doctors who didn't wash their hands? (Hospitals are a breeding ground for antibiotic-resistant pathogens like MRSA.) Another interesting article is Atul Gawande's "The Checklist" [1] (later expanded into a book), which describes how the use of simple checklists, similar to those that pilots use, can prevent medical errors like operating on the wrong body part. [1] http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande?currentPage=all http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_...
- 7952 14y ago
  Great read, thanks. "The tasks of medical science fall into three buckets. One is understanding disease biology. One is finding effective therapies. And one is insuring those therapies are delivered effectively. That third bucket has been almost totally ignored by research funders, government, and academia."
  - HarryHirsch 14y ago
    Bucket 3 actually conflates public health and industrial safety. But one wonders where he got that idea from. There is ample research in public health, although perhaps not so much in the US, as a hospital or pharmco you cannot make money from it, and there is ample research on industrial safety as well. Airlines know a hell of the last thing - cockpit management, checklists, the works. I seem to remember Atul Gawande discussing this last item.
- bryanlarsen 14y ago
  "There's something seriously wrong with the medical profession if doctors only wash their hands 90% of the time" It's not that they're failing to wash their hands 10% of the time, it's that they're not washing their hands properly 10% of the time. We don't know if the incompleteness is significant or insignificant.
  - InclinedPlane 14y ago
    Exactly. And the previous problem wasn't that doctors and nurses weren't washing their hands, it was that they weren't washing them well enough. A quick wash as one might do before eating a meal is not the same level of washing as required for someone who has had their hands exposed to, say, MRSA or who is about to interact with a sick patient.
  - konstruktor 14y ago
    If that's what they actually checked, I can see doctors avoiding washing at the washing stations to not get caught with errors, which is even worse than getting it wrong. Talk about bad incentives... However, I would consider bad hand washing almost as neglegient. It's really not rocket science
    - mcmatterson 14y ago
      Actually, it is. This is a classic example of blaming the offender and not the process. Many hospitals (and this is borne out by research conducted by colleagues of mine; I'm not making this up) don't even have soap dispensers near sinks. Some hospitals mistakenly cross-label hand sanitizer and soap. Things are simple as housekeeping being late refilling paper towel dispensers cause drops in adherence rates. Can you carry a coffee cup from room to room, or is that an infection vector as well? What about chart updating? Do you wash your hands before or after touching a shared computer keyboard at the nursing station (answer: both, but many nursing stations don't have sinks). Blaming healthcare providers for not washing their hands is like blaming John Q Public for the housing crisis. The reality is much, much more complicated, and solutions to the problem are equally so. Healthcare is an incredibly complicated ecosystem, and even things are simple as hand washing are affected by dozens of factors, many of which are non-obvious at first. Root cause analysis and a judicious application of process change can help greatly, but the reality is that even simple things such as this do not change overnight in healthcare. It's harder than you think.
- Alex3917 14y ago
  Actually there is some (possibly) good news on this. The CDC guestimates that central-line associated blood stream infections (CLABSIs) declined by 58% in ICUs, from 43,000 to 18,000. While this is only a rough estimate (not a measurement) based on poor data, Provnost (the guy in the New Yorker article) did refer to the results as "the first national success we have for patient safety in this country." (So this is positive, but note the implication.) The bad news is that the majority of CLABSIs happen outside of the ICU where there is no previous data. For these non-ICU settings, the CDC writes, "efforts to improve central line insertion might have limited impact." ("In 2009, an estimated 23,000 CLABSIs occurred among patients in inpatient wards and, in 2008, an estimated 37,000 CLABSIs occurred among patients receiving outpatient hemodialysis.") Also, CLABSIs account for only a very small percentage of all hospital acquired infections. Sources: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6008a4.htm/ http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6008a4.htm/ http://www.ama-assn.org/amednews/2011/03/14/prl20314.htm http://www.ama-assn.org/amednews/2011/03/14/prl20314.htm
  - mcmatterson 14y ago
    I've worked in the healthcare field for many years, and have written protocols and supporting applications to measure practise standards around central line procedures (both in and out of ICU environments), and I can say quite definitively that while CLI infections as a result of procedural mistakes happen, they are not the low hanging fruit you think they are. If I had to nominate three low hanging fruits with respect to medical errors, they would be: - Hand washing. Colleagues of mine have researched and written extensively about this issue; study after study bears out the numbers people are quoting here. I'll source some references and reply with them. - Positive patient ID. The high flying stories about operating on the wrong patient, or on the wrong limb are one thing, but much more sinister is the issue of mislabeled blood work, specialist reports that are delayed due to mismatched paperwork, and medication mis-administration (more on this later). The degree to which healthcare professionals operate in an environment of mislabeled, misattributed, and simply missing documentation is astounding. - Medication Administration. A close colleague of mine has made a career around studying the practice of chemotherapy administration and the reduction of errors therein. The feedback she gets when presenting to practitioners is both very encouraging (they, of course, genuinely want to improve their practice), and also disheartening (very simple changes to process have simply never occurred to many front-line staff. They're consistently amazed that the idea of process improvement is even a thing). If you've ever been in the unfortunate position of having to see chemo being (properly) administered, you get to see firsthand how rigorous process controls are supposed to work. Every bag that gets hung is triple checked via different calculation paths, every patient's identity is re-confirmed every time (even patients that have been on the ward for months), and every interaction with infusion pumps is double checked by at least two nurses after every action. It's a great thing to witness; it's just sad that it isn't the norm everywhere in healthcare.
- firefoxman1 14y ago
  Things like "Jiro Dreams of Sushi" make you realise how few people treat their job as a "craft" let alone a profession. I can't remember a single time in school being taught that what I should be striving for in a "career" is mastery, excellence, or to even take pride in my work. When you don't care about your craft, stuff like this happens.
marshallp 14y ago
The only real solution to healthcare is to reduce costs by eliminating hospitals/doctors altogether using big data/telerobotics/smartphones. Sadly, because of the AMA and FDA this innovation will have to occur offshore first.
- daeken 14y ago
  This seems deeply, deeply misguided. Let's say you eliminate hospitals -- where are you going to get surgery? Even if it's done by remotely controlled robots, it's not exactly going to happen in your house, since it's not a sterile environment. What about when you break your leg; do you expect a robot ambulance to drive up an treat you in your driveway? Hospitals and doctors alike have to change to make things better -- more advanced technology, different business models, etc -- but throwing them away entirely is just downright silly.
  - marshallp 14y ago
    Yes, the robots should drive to your driveway in a bubble of sterility. I'm not suggesting this happen by tommorrow, just that it is technically possible with the enough investment. I'm just suggesting that when it comes to medical matters innovation is happening at a snails pace. The aerospace industry manages to lose almost no lives, while the medical industry loses people left and right. There's something deeply wrong there. Recently, Vinod Khosla suggested 80 percent of doctors are superfluous and medicine still operates in a voodoo magic kind of way for the most part.
    - Gatsky 14y ago
      Despite the revelation on HN that there are high error rates in medicine, this problem has been well known for a long time. So here is the easy problem: using information technology to help doctors deliver high quality healthcare. Here is the hard problem: replacing the entire health system with technofantasy buzzword medicine. If no one can solve the easy problem, why should we listen to anyone who thinks they can solve the hard problem? That's the voodoo magic. If you want to get rid of 80% of doctors, then you would need to think of how to replace the role of the doctor in the following situations, which crop up every day in the hospital: Making the decision to stop chemotherapy balancing the risks and benefits in a patient with advanced cancer that has failed multiple lines of treatment. Managing a patient with borderline personality disorder who tried to hang herself early that day and needs to be observed medically who is demanding at all costs to walk outside and smoke. Managing a patient with chronic severe abdominal pain of unknown aetiology, that has had all the tests known to man, multiple surgeries etc with no result. Managing a patient with severe emphysema who passes out at home from breathing failure, comes to ED, gets resuscitated, then rips off the mask and drives home on her scooter. Repeat this 150 times a year. A woman has advanced cancer. She is dying, no treatment will benefit her. The family decides to keep her comfortable. Her last son finally comes back from overseas and starts demanding that everything be done to save her. So this is the thing... Doctors do lots of things, they do tests, they think, they prescribe drugs, they do surgery etc etc... all of those can be replaced by other specialised practitioners and probably robots one day. But what they actually, really do, most of the time, is take responsibility for a patient, in the face of often great uncertainty and very imperfect science.
anigbrowl 14y ago
The US is rated worst among developed nations for this sort of thing: http://www.commonwealthfund.org/News/News-Releases/2005/Nov/International-Survey--U-S--Leads-in-Medical-Errors.aspx http://www.commonwealthfund.org/News/News-Releases/2005/Nov/... I was in hospital following an accident last year. When I was discharged from the ICU the following day, the nurse gave me the paperwork for the patient in the next room. I didn't notice, being still rather beaten up by the whole episode - it was my wife who spotted it. For a 12 hour stay I ended up paying over $15,000, and then I hard to fork over an extra $90 to get copies of the medical record. On paper. I'll take socialized medicine any day of the week. the private sector does a terrible job of healthcare.
- Alex3917 14y ago
  "I'll take socialized medicine any day of the week. the private sector does a terrible job of healthcare." This. The average hospital patient is the victim of 1 medical error per day, and ~10% of those lead to death or permanent disability. So you could literally go into the hospital being perfectly healthy, and odds are that you'd be dead or disabled in little over a week. edit: Ignore this, I was mixing two different statistics that, while both accurate, don't seem to be compatible. There is better data below.
  - shasta 14y ago
    Are you serious?
    - Alex3917 14y ago
      Yeah, that is actually a slight underestimate. Basically the average hospital patient receives 120 procedures per day, with a 1% error rate. Of those errors, an estimated 10 - 15% cause death or disability. The links I posted in my other comment to that IOM article and the Leape analysis of it basically support this, although I can't find an exact cite for that 120 procedures per day stat. edit: It looks like I'm mixing measurements slightly. Basically I did find the source of that stat, it is here: "There was an average of 178 activities per patient per day and an estimated number of 1.7 errors per patient per day. For the ICU as a whole, a severe or potentially detrimental error occurred on the average twice a day. Physicians and nurses were about equal contributors to the number of errors, although nurses had many more activities per day." http://www.ncbi.nlm.nih.gov/pubmed/7867355 http://www.ncbi.nlm.nih.gov/pubmed/7867355 However, this is from the IOM report: "Two large studies, one conducted in Colorado and Utah and the other in New York, found that adverse events occurred in 2.9 and 3.7 percent of hospitalizations, respectively. In Colorado and Utah hospitals, 6.6 percent of adverse events led to death, as compared with 13.6 percent in New York hospitals. In both of these studies, over half of these adverse events resulted from medical errors and could have been prevented. When extrapolated to the over 33.6 million admissions to U.S. hospitals in 1997, the results of the study in Colorado and Utah imply that at least 44,000 Americans die each year as a result of medical errors. The results of the New York Study suggest the number may be as high as 98,000." Also from the IOM report: "In a study of 1,047 patients admitted to two intensive care units and one surgical unit at a large teaching hospital, 480 (45.8 percent) were identified as having had an adverse event, where adverse event was defined as “situations in which an inappropriate decision was made when, at the time, an appropriate alternative could have been chosen.” 41 For 185 patients (17.7 percent), the adverse event was serious, producing disability or death. The likelihood of experiencing an adverse event increased about six percent for each day of hospital stay." Then Leape in his own analysis explains why even the 98,000 figure is probably a fairly large underestimate: "The [IOM] study’s most serious limitation is probably that it was a retrospective medical record review study. Many important events in patient care are not recorded in the medical record. Some errors are not even known to clinicians caring for the patient. Studies of autopsy, for example, have found potentially fatal misdiagnoses in 20% to 40% of cases. On balance, the reliance on information extracted from medical records most likely led to a substantial underestimate of the prevalence of injury." "They undoubtedly missed some that did occur because many adverse events and errors are never recorded in the medical record, either because they are concealed or not recognized. Other errors are discovered after the patient is discharged. In fact, in the MPS, an additional 6% of hospital-caused adverse events were discovered after discharge, but were excluded from the analyses because they were an unknown fraction of all such events. Therefore, any record-review study produces at best a 'lower bound.'" "Second, neither of the large studies examined the extent of injuries that occur outside of the hospital. More than half of surgical procedures (numbering now in the tens of millions) take place outside of a hospital setting, and the adverse event rates for these procedures have not been studied. Even if complication and death rates are much lower than in-hospital care, the absolute numbers must be substantial, as suggested by the recent report of deaths associated with liposuction." "Third, when prospective detailed studies are performed, error and injury rates are almost invariably much higher than indicated by the large record-review studies. In a large study of patients who died from acute myocardial infarction, pneumonia, or cerebrovascular accident (conditions that account for 36% of all hospital deaths), DuBois and Brook found that 14% to 27% of deaths were preventable. Andrews et al found that 17% of intensive care unit patients had preventable serious or fatal adverse events. The Centers for Disease Control and Prevention estimates that 500,000 surgical-site infections occur each year. One large controlled study found the excess mortality rate of surgical-site infections to be 4.3%, suggesting 20,000 deaths annually from this cause alone. These data are strong evidence that record-review studies seriously underestimate the extent of medical injury."
Alex3917 14y ago
"If medical errors were a disease, they would be the sixth leading cause of death in America—just behind accidents and ahead of Alzheimer's." This is wrong, it's at least the third leading cause of death. And realistically if you don't smoke and you exercise once in a while, medical 'oopsy daisies' are probably your #1 risk of death: C.f. The IOM's report To Err is Human: http://wps.pearsoneducation.nl/wps/media/objects/13902/14236351/H%2007_To%20Err%20Is%20Human.pdf http://wps.pearsoneducation.nl/wps/media/objects/13902/14236... And then also read Lucian Leape's commentary in JAMA on why it is probably a huge underestimate: http://jama.jamanetwork.com/article.aspx?articleid=192842 http://jama.jamanetwork.com/article.aspx?articleid=192842 (Leape is one of the authors of the original IOM report, and the report cites a lot of his own research, including his study estimating that only 5% of medical errors are ever discovered.) C.f. also Barbara Starfield's estimate in JAMA: http://jama.jamanetwork.com/article.aspx?articleid=192908#REF-JCO00061-1 http://jama.jamanetwork.com/article.aspx?articleid=192908#RE... Realistically, all of these estimates are at the low end. In fact most of them only count deaths in hospitals (and severely undercount them), when at least half of all medical errors are thought to happen at local doctors offices, plastic surgery clinics, nursing homes, etc. C.f. also the CDC figures for Hospital Acquired Infections, which IIRC the IOM report doesn't count as being medical errors: http://www.cdc.gov/HAI/pdfs/hai/infections_deaths.pdf http://www.cdc.gov/HAI/pdfs/hai/infections_deaths.pdf My personal rule of thumb is to avoid taking any drugs or getting any non-trivial medical procedure unless I've read at least three books about it. The problem is that all the papers published in medical journals are basically complete bullshit (except the occasional well-done NIH ones), which means if you want real information about a given drug then the only way to get it is to subpoena the FDA, or read a book written by someone who has. The way drug approval works is that you need 2 tests demonstrating that the drug is better than a placebo, but you're allowed infinite tries to get there. So often a drug will be better than a placebo in only 2 out of 10 trials, but it will still get approved and only those two trials will get published in medical journals. And then those journal articles will have very little in common with the actual data from the FDA trials because the pharma companies completely spin it, which is why the vast majority of the most popularly prescribed drugs are not only no more effective than placebos, but in fact significantly worse when you look at the total quality/length of life.
- 14y ago
ivix 14y ago
The NHS already provides this data: https://indicators.ic.nhs.uk/webview/ https://indicators.ic.nhs.uk/webview/ The spreadsheet: http://indicators.ic.nhs.uk/download/SHMI/July_2012/Data/SHMI.xls http://indicators.ic.nhs.uk/download/SHMI/July_2012/Data/SHM... Sadly, you can pretty much guess the results. Poorer areas = higher death rates.
w1ntermute 14y ago
In an industry as tightly regulated as medicine, it's not surprising that such enormous inaccuracies have not been worked out. No matter what medical professionals might say about wanting to save people's lives, the ubiquitous motivator of economics is a much more powerful incentive. Unfortunately, since the industry is not open to being influenced by the free market, it will be very difficult to break into the industry and jump start that innovation. It will be very interesting to see if developing countries manage to leapfrog our current system and establish a medical industry that is less dependent on people.
- gcb 14y ago
  Regulation is to protect access to the market, not quality of offerings... Usually it does exactly the opposite.
rayiner 14y ago
But the malpractice lawyers are terrible! Tort reform!
- mkopinsky 14y ago
  You joke (I think), but tort reform actually has the potential to enable/encourage some of what is mentioned in this article - when mistakes are something that we can't even talk about for fear of gazillion dollar repercussions, it's hard to do anything to fix the problem.
lostlogin 14y ago
It would be interesting to see stats compared between 'socialized' systems (we call it the public system) and private systems. When everyone has the same boss (Minister of Health) and is working within the same rules and guidelines it must do something to the stats. We do have a private healthcare service, but its basically restricted to simpler day stay (or slightly longer stays) surgery and less complex procedures. There are no private emergency healthcare hospitals here that I know of. New Zealand is the country. The system is far from perfect here, but I'm yet to learn of a system I'd prefer.
bryans 14y ago
It's amazing how easy it is for tiny mistakes to result in serious consequences. I have a medical condition that took over two years to officially diagnose. During one of my hospital stays toward the beginning of that ordeal, a doctor had decided that my issue required major surgery involving the removal of an organ. Less than one day before the scheduled surgery, the doctor decided to do "one more test" for an easily treatable condition. As it turned out, he had misread a previous doctor's note suggesting a possible diagnosis, as a dismissal of the diagnosis. I'll never know whether the confusion was due to poor handwriting or poor attention to detail, but I feel lucky that the error was caught in time. I met multiple people during my numerous, lengthy visits whom I suspect were not as lucky.
tokenadult 14y ago
From the submitted article: "Nothing makes hospitals shape up more quickly than this kind of public reporting. In 1989, the first year that New York's hospitals were required to report heart-surgery death rates, the death rate by hospital ranged from 1% to 18%—a huge gap. Consumers were finally armed with useful data. They could ask: "Why have a coronary artery bypass graft operation at a place where you have a 1-in-6 chance of dying compared with a hospital with a 1-in-100 chance of dying?" "Instantly, New York heart hospitals with high mortality rates scrambled to improve; death rates declined by 83% in six years. Management at these hospitals finally asked staff what they had to do to make care safer. At some hospitals, the surgeons said they needed anesthesiologists who specialized in heart surgery; at others, nurse practitioners were brought in. At one hospital, the staff reported that a particular surgeon simply wasn't fit to be operating. His mortality rate was so high that it was skewing the hospital's average. Administrators ordered him to stop doing heart surgery. Goodbye, Dr. Hodad." So we have a known model that improves results. Let the patients who decide which hospitals to visit know beforehand how hospitals compare in getting good results for patients. Give patients power to shop. That provides incentives for hospitals to do better, and nudges hospital managers to do what is necessary to win the trust of informed patients. This kind of reform would be very good to apply to schools as well. Already, one state in the United States that is conspicuous among all fifty states in educational achievement (the state I live in) allows all residents of the state to enroll in the public schools of ANY school district anywhere in the state. (The school district I live in has inbound open-enrollment students from the geographical territories of forty-one other school districts.) In general, the power to shop is the incentive factor to bolster by government regulation, letting each consumer decide what trade-offs are important. That works considerably better in driving improvement than regulating outcome goals, and better still than regulating inputs into the provision of the important service being regulated.
- jonah 14y ago
  Real data and informed consumers are a very valid way to promote improvement through "competition". Often times though, that's not enough as is the case in LA right now where patients are being prevented from using the best doctors: Two of the most prestigious names in Southern California healthcare — Cedars-Sinai and UCLA — are getting shut out of a major insurance plan for being too expensive. In a bold cost-cutting move, Anthem Blue Cross has eliminated doctors affiliated with the hospitals from a health plan offered to about 60,000 employees and dependents at the cash-strapped city of Los Angeles. The city opted for Anthem's plan because it will save $7.6 million in annual premiums next year by excluding physicians from the two institutions known for tending to the Southland's rich and famous. About 2,200 city workers and family members are expected to lose access to their doctors under the plan. This dramatic step shows that even some of the most-respected names in medicine can't get by on reputation alone at a time when the U.S. is grappling with a $2.6-trillion healthcare bill annually. Major hospitals and medical groups face growing pressure to justify their charges. And employers increasingly are willing to risk the ire of workers by cutting popular providers to clamp down on costs. - http://www.latimes.com/business/la-fi-hospital-costs-20120921,0,2292633.story http://www.latimes.com/business/la-fi-hospital-costs-2012092...
Riesling 14y ago
The current state of medicine is extremely frightening. Note 1: My comments here relate to the German health system, with which I am most familiar with, but I assume that other systems work similar, if not less efficiently. In my opinion, there are many other problems in the broad field of medicine, but the following two points could be resolved with the support of IT, so I will confine my remarks to those. 1. Plausibility checks Virtually no plausibility checks will be carried out in todays hospitals. Often conflicting drugs are prescribed, which produce uncomfortable side effects. One should start to make all medications and treatment measures subject to automatic (computer based) plausibility checks. This would also lead to a cognitive relief of the clinical staff. 2. Statistical evaluations (data mining) The lack of inadequate statistical analysis is another concern. Germany has begun to build a national cancer database only this year. One can only imagine what valuable information is hidden in those statistics and have been missed up to this day. Imagine an international database in which all patients who are admitted as an emergency to the hospital are captured statistically. This data could be stored completely anonymous. The only thing of importance would be the provision of relevant laboratory values and the patient's symptoms described in the context of the (verified) final diagnosis. Such a system could support the finding of completely new knowledge (data mining) and support the doctor in finding the right diagnosis. And of course the hospitals need strong incentives to implement these measures. Which is why I support the author's call for absolute transparency.

153 points by bmahmood 14y ago

I feel sorry for everyone involved in this complex industry, no arena of which is aligned with the goal of people's long term health. The common sense suggestions in this article are a good step towards improving things by increasing transparency and accountability via documentation but may not address the root problems.

greenyoda 14y ago

"A few years ago, Long Island's North Shore University Hospital had a dismal compliance rate with hand washing—under 10%. After installing cameras at hand-washing stations, compliance rose to over 90% and stayed there." There's something seriously wrong with the medical profession if doctors only wash their hands 90% of the time, even if they know they're being watched. The words "reckless disregard for human life" spring to mind. How many deaths from infections per year could be prevented if hospitals just fired any doctors who didn't wash their hands? (Hospitals are a breeding ground for antibiotic-resistant pathogens like MRSA.) Another interesting article is Atul Gawande's "The Checklist" [1] (later expanded into a book), which describes how the use of simple checklists, similar to those that pilots use, can prevent medical errors like operating on the wrong body part. [1] http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande?currentPage=all http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_...

7952 14y ago
Great read, thanks. "The tasks of medical science fall into three buckets. One is understanding disease biology. One is finding effective therapies. And one is insuring those therapies are delivered effectively. That third bucket has been almost totally ignored by research funders, government, and academia."
- HarryHirsch 14y ago
  Bucket 3 actually conflates public health and industrial safety. But one wonders where he got that idea from. There is ample research in public health, although perhaps not so much in the US, as a hospital or pharmco you cannot make money from it, and there is ample research on industrial safety as well. Airlines know a hell of the last thing - cockpit management, checklists, the works. I seem to remember Atul Gawande discussing this last item.
bryanlarsen 14y ago
"There's something seriously wrong with the medical profession if doctors only wash their hands 90% of the time" It's not that they're failing to wash their hands 10% of the time, it's that they're not washing their hands properly 10% of the time. We don't know if the incompleteness is significant or insignificant.
- InclinedPlane 14y ago
  Exactly. And the previous problem wasn't that doctors and nurses weren't washing their hands, it was that they weren't washing them well enough. A quick wash as one might do before eating a meal is not the same level of washing as required for someone who has had their hands exposed to, say, MRSA or who is about to interact with a sick patient.
- konstruktor 14y ago
  If that's what they actually checked, I can see doctors avoiding washing at the washing stations to not get caught with errors, which is even worse than getting it wrong. Talk about bad incentives... However, I would consider bad hand washing almost as neglegient. It's really not rocket science
  - mcmatterson 14y ago
    Actually, it is. This is a classic example of blaming the offender and not the process. Many hospitals (and this is borne out by research conducted by colleagues of mine; I'm not making this up) don't even have soap dispensers near sinks. Some hospitals mistakenly cross-label hand sanitizer and soap. Things are simple as housekeeping being late refilling paper towel dispensers cause drops in adherence rates. Can you carry a coffee cup from room to room, or is that an infection vector as well? What about chart updating? Do you wash your hands before or after touching a shared computer keyboard at the nursing station (answer: both, but many nursing stations don't have sinks). Blaming healthcare providers for not washing their hands is like blaming John Q Public for the housing crisis. The reality is much, much more complicated, and solutions to the problem are equally so. Healthcare is an incredibly complicated ecosystem, and even things are simple as hand washing are affected by dozens of factors, many of which are non-obvious at first. Root cause analysis and a judicious application of process change can help greatly, but the reality is that even simple things such as this do not change overnight in healthcare. It's harder than you think.
Alex3917 14y ago
Actually there is some (possibly) good news on this. The CDC guestimates that central-line associated blood stream infections (CLABSIs) declined by 58% in ICUs, from 43,000 to 18,000. While this is only a rough estimate (not a measurement) based on poor data, Provnost (the guy in the New Yorker article) did refer to the results as "the first national success we have for patient safety in this country." (So this is positive, but note the implication.) The bad news is that the majority of CLABSIs happen outside of the ICU where there is no previous data. For these non-ICU settings, the CDC writes, "efforts to improve central line insertion might have limited impact." ("In 2009, an estimated 23,000 CLABSIs occurred among patients in inpatient wards and, in 2008, an estimated 37,000 CLABSIs occurred among patients receiving outpatient hemodialysis.") Also, CLABSIs account for only a very small percentage of all hospital acquired infections. Sources: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6008a4.htm/ http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6008a4.htm/ http://www.ama-assn.org/amednews/2011/03/14/prl20314.htm http://www.ama-assn.org/amednews/2011/03/14/prl20314.htm
- mcmatterson 14y ago
  I've worked in the healthcare field for many years, and have written protocols and supporting applications to measure practise standards around central line procedures (both in and out of ICU environments), and I can say quite definitively that while CLI infections as a result of procedural mistakes happen, they are not the low hanging fruit you think they are. If I had to nominate three low hanging fruits with respect to medical errors, they would be: - Hand washing. Colleagues of mine have researched and written extensively about this issue; study after study bears out the numbers people are quoting here. I'll source some references and reply with them. - Positive patient ID. The high flying stories about operating on the wrong patient, or on the wrong limb are one thing, but much more sinister is the issue of mislabeled blood work, specialist reports that are delayed due to mismatched paperwork, and medication mis-administration (more on this later). The degree to which healthcare professionals operate in an environment of mislabeled, misattributed, and simply missing documentation is astounding. - Medication Administration. A close colleague of mine has made a career around studying the practice of chemotherapy administration and the reduction of errors therein. The feedback she gets when presenting to practitioners is both very encouraging (they, of course, genuinely want to improve their practice), and also disheartening (very simple changes to process have simply never occurred to many front-line staff. They're consistently amazed that the idea of process improvement is even a thing). If you've ever been in the unfortunate position of having to see chemo being (properly) administered, you get to see firsthand how rigorous process controls are supposed to work. Every bag that gets hung is triple checked via different calculation paths, every patient's identity is re-confirmed every time (even patients that have been on the ward for months), and every interaction with infusion pumps is double checked by at least two nurses after every action. It's a great thing to witness; it's just sad that it isn't the norm everywhere in healthcare.
firefoxman1 14y ago
Things like "Jiro Dreams of Sushi" make you realise how few people treat their job as a "craft" let alone a profession. I can't remember a single time in school being taught that what I should be striving for in a "career" is mastery, excellence, or to even take pride in my work. When you don't care about your craft, stuff like this happens.

marshallp 14y ago

The only real solution to healthcare is to reduce costs by eliminating hospitals/doctors altogether using big data/telerobotics/smartphones. Sadly, because of the AMA and FDA this innovation will have to occur offshore first.

daeken 14y ago
This seems deeply, deeply misguided. Let's say you eliminate hospitals -- where are you going to get surgery? Even if it's done by remotely controlled robots, it's not exactly going to happen in your house, since it's not a sterile environment. What about when you break your leg; do you expect a robot ambulance to drive up an treat you in your driveway? Hospitals and doctors alike have to change to make things better -- more advanced technology, different business models, etc -- but throwing them away entirely is just downright silly.
- marshallp 14y ago
  Yes, the robots should drive to your driveway in a bubble of sterility. I'm not suggesting this happen by tommorrow, just that it is technically possible with the enough investment. I'm just suggesting that when it comes to medical matters innovation is happening at a snails pace. The aerospace industry manages to lose almost no lives, while the medical industry loses people left and right. There's something deeply wrong there. Recently, Vinod Khosla suggested 80 percent of doctors are superfluous and medicine still operates in a voodoo magic kind of way for the most part.
  - Gatsky 14y ago
    Despite the revelation on HN that there are high error rates in medicine, this problem has been well known for a long time. So here is the easy problem: using information technology to help doctors deliver high quality healthcare. Here is the hard problem: replacing the entire health system with technofantasy buzzword medicine. If no one can solve the easy problem, why should we listen to anyone who thinks they can solve the hard problem? That's the voodoo magic. If you want to get rid of 80% of doctors, then you would need to think of how to replace the role of the doctor in the following situations, which crop up every day in the hospital: Making the decision to stop chemotherapy balancing the risks and benefits in a patient with advanced cancer that has failed multiple lines of treatment. Managing a patient with borderline personality disorder who tried to hang herself early that day and needs to be observed medically who is demanding at all costs to walk outside and smoke. Managing a patient with chronic severe abdominal pain of unknown aetiology, that has had all the tests known to man, multiple surgeries etc with no result. Managing a patient with severe emphysema who passes out at home from breathing failure, comes to ED, gets resuscitated, then rips off the mask and drives home on her scooter. Repeat this 150 times a year. A woman has advanced cancer. She is dying, no treatment will benefit her. The family decides to keep her comfortable. Her last son finally comes back from overseas and starts demanding that everything be done to save her. So this is the thing... Doctors do lots of things, they do tests, they think, they prescribe drugs, they do surgery etc etc... all of those can be replaced by other specialised practitioners and probably robots one day. But what they actually, really do, most of the time, is take responsibility for a patient, in the face of often great uncertainty and very imperfect science.

anigbrowl 14y ago

The US is rated worst among developed nations for this sort of thing: http://www.commonwealthfund.org/News/News-Releases/2005/Nov/International-Survey--U-S--Leads-in-Medical-Errors.aspx http://www.commonwealthfund.org/News/News-Releases/2005/Nov/... I was in hospital following an accident last year. When I was discharged from the ICU the following day, the nurse gave me the paperwork for the patient in the next room. I didn't notice, being still rather beaten up by the whole episode - it was my wife who spotted it. For a 12 hour stay I ended up paying over $15,000, and then I hard to fork over an extra $90 to get copies of the medical record. On paper. I'll take socialized medicine any day of the week. the private sector does a terrible job of healthcare.

Alex3917 14y ago
"I'll take socialized medicine any day of the week. the private sector does a terrible job of healthcare." This. The average hospital patient is the victim of 1 medical error per day, and ~10% of those lead to death or permanent disability. So you could literally go into the hospital being perfectly healthy, and odds are that you'd be dead or disabled in little over a week. edit: Ignore this, I was mixing two different statistics that, while both accurate, don't seem to be compatible. There is better data below.
- shasta 14y ago
  Are you serious?
  - Alex3917 14y ago
    Yeah, that is actually a slight underestimate. Basically the average hospital patient receives 120 procedures per day, with a 1% error rate. Of those errors, an estimated 10 - 15% cause death or disability. The links I posted in my other comment to that IOM article and the Leape analysis of it basically support this, although I can't find an exact cite for that 120 procedures per day stat. edit: It looks like I'm mixing measurements slightly. Basically I did find the source of that stat, it is here: "There was an average of 178 activities per patient per day and an estimated number of 1.7 errors per patient per day. For the ICU as a whole, a severe or potentially detrimental error occurred on the average twice a day. Physicians and nurses were about equal contributors to the number of errors, although nurses had many more activities per day." http://www.ncbi.nlm.nih.gov/pubmed/7867355 http://www.ncbi.nlm.nih.gov/pubmed/7867355 However, this is from the IOM report: "Two large studies, one conducted in Colorado and Utah and the other in New York, found that adverse events occurred in 2.9 and 3.7 percent of hospitalizations, respectively. In Colorado and Utah hospitals, 6.6 percent of adverse events led to death, as compared with 13.6 percent in New York hospitals. In both of these studies, over half of these adverse events resulted from medical errors and could have been prevented. When extrapolated to the over 33.6 million admissions to U.S. hospitals in 1997, the results of the study in Colorado and Utah imply that at least 44,000 Americans die each year as a result of medical errors. The results of the New York Study suggest the number may be as high as 98,000." Also from the IOM report: "In a study of 1,047 patients admitted to two intensive care units and one surgical unit at a large teaching hospital, 480 (45.8 percent) were identified as having had an adverse event, where adverse event was defined as “situations in which an inappropriate decision was made when, at the time, an appropriate alternative could have been chosen.” 41 For 185 patients (17.7 percent), the adverse event was serious, producing disability or death. The likelihood of experiencing an adverse event increased about six percent for each day of hospital stay." Then Leape in his own analysis explains why even the 98,000 figure is probably a fairly large underestimate: "The [IOM] study’s most serious limitation is probably that it was a retrospective medical record review study. Many important events in patient care are not recorded in the medical record. Some errors are not even known to clinicians caring for the patient. Studies of autopsy, for example, have found potentially fatal misdiagnoses in 20% to 40% of cases. On balance, the reliance on information extracted from medical records most likely led to a substantial underestimate of the prevalence of injury." "They undoubtedly missed some that did occur because many adverse events and errors are never recorded in the medical record, either because they are concealed or not recognized. Other errors are discovered after the patient is discharged. In fact, in the MPS, an additional 6% of hospital-caused adverse events were discovered after discharge, but were excluded from the analyses because they were an unknown fraction of all such events. Therefore, any record-review study produces at best a 'lower bound.'" "Second, neither of the large studies examined the extent of injuries that occur outside of the hospital. More than half of surgical procedures (numbering now in the tens of millions) take place outside of a hospital setting, and the adverse event rates for these procedures have not been studied. Even if complication and death rates are much lower than in-hospital care, the absolute numbers must be substantial, as suggested by the recent report of deaths associated with liposuction." "Third, when prospective detailed studies are performed, error and injury rates are almost invariably much higher than indicated by the large record-review studies. In a large study of patients who died from acute myocardial infarction, pneumonia, or cerebrovascular accident (conditions that account for 36% of all hospital deaths), DuBois and Brook found that 14% to 27% of deaths were preventable. Andrews et al found that 17% of intensive care unit patients had preventable serious or fatal adverse events. The Centers for Disease Control and Prevention estimates that 500,000 surgical-site infections occur each year. One large controlled study found the excess mortality rate of surgical-site infections to be 4.3%, suggesting 20,000 deaths annually from this cause alone. These data are strong evidence that record-review studies seriously underestimate the extent of medical injury."

Alex3917 14y ago

"If medical errors were a disease, they would be the sixth leading cause of death in America—just behind accidents and ahead of Alzheimer's." This is wrong, it's at least the third leading cause of death. And realistically if you don't smoke and you exercise once in a while, medical 'oopsy daisies' are probably your #1 risk of death: C.f. The IOM's report To Err is Human: http://wps.pearsoneducation.nl/wps/media/objects/13902/14236351/H%2007_To%20Err%20Is%20Human.pdf http://wps.pearsoneducation.nl/wps/media/objects/13902/14236... And then also read Lucian Leape's commentary in JAMA on why it is probably a huge underestimate: http://jama.jamanetwork.com/article.aspx?articleid=192842 http://jama.jamanetwork.com/article.aspx?articleid=192842 (Leape is one of the authors of the original IOM report, and the report cites a lot of his own research, including his study estimating that only 5% of medical errors are ever discovered.) C.f. also Barbara Starfield's estimate in JAMA: http://jama.jamanetwork.com/article.aspx?articleid=192908#REF-JCO00061-1 http://jama.jamanetwork.com/article.aspx?articleid=192908#RE... Realistically, all of these estimates are at the low end. In fact most of them only count deaths in hospitals (and severely undercount them), when at least half of all medical errors are thought to happen at local doctors offices, plastic surgery clinics, nursing homes, etc. C.f. also the CDC figures for Hospital Acquired Infections, which IIRC the IOM report doesn't count as being medical errors: http://www.cdc.gov/HAI/pdfs/hai/infections_deaths.pdf http://www.cdc.gov/HAI/pdfs/hai/infections_deaths.pdf My personal rule of thumb is to avoid taking any drugs or getting any non-trivial medical procedure unless I've read at least three books about it. The problem is that all the papers published in medical journals are basically complete bullshit (except the occasional well-done NIH ones), which means if you want real information about a given drug then the only way to get it is to subpoena the FDA, or read a book written by someone who has. The way drug approval works is that you need 2 tests demonstrating that the drug is better than a placebo, but you're allowed infinite tries to get there. So often a drug will be better than a placebo in only 2 out of 10 trials, but it will still get approved and only those two trials will get published in medical journals. And then those journal articles will have very little in common with the actual data from the FDA trials because the pharma companies completely spin it, which is why the vast majority of the most popularly prescribed drugs are not only no more effective than placebos, but in fact significantly worse when you look at the total quality/length of life.

14y ago

ivix 14y ago

The NHS already provides this data: https://indicators.ic.nhs.uk/webview/ https://indicators.ic.nhs.uk/webview/ The spreadsheet: http://indicators.ic.nhs.uk/download/SHMI/July_2012/Data/SHMI.xls http://indicators.ic.nhs.uk/download/SHMI/July_2012/Data/SHM... Sadly, you can pretty much guess the results. Poorer areas = higher death rates.

w1ntermute 14y ago

In an industry as tightly regulated as medicine, it's not surprising that such enormous inaccuracies have not been worked out. No matter what medical professionals might say about wanting to save people's lives, the ubiquitous motivator of economics is a much more powerful incentive. Unfortunately, since the industry is not open to being influenced by the free market, it will be very difficult to break into the industry and jump start that innovation. It will be very interesting to see if developing countries manage to leapfrog our current system and establish a medical industry that is less dependent on people.

gcb 14y ago
Regulation is to protect access to the market, not quality of offerings... Usually it does exactly the opposite.

rayiner 14y ago

But the malpractice lawyers are terrible! Tort reform!

mkopinsky 14y ago
You joke (I think), but tort reform actually has the potential to enable/encourage some of what is mentioned in this article - when mistakes are something that we can't even talk about for fear of gazillion dollar repercussions, it's hard to do anything to fix the problem.

lostlogin 14y ago

It would be interesting to see stats compared between 'socialized' systems (we call it the public system) and private systems. When everyone has the same boss (Minister of Health) and is working within the same rules and guidelines it must do something to the stats. We do have a private healthcare service, but its basically restricted to simpler day stay (or slightly longer stays) surgery and less complex procedures. There are no private emergency healthcare hospitals here that I know of. New Zealand is the country. The system is far from perfect here, but I'm yet to learn of a system I'd prefer.

bryans 14y ago

It's amazing how easy it is for tiny mistakes to result in serious consequences. I have a medical condition that took over two years to officially diagnose. During one of my hospital stays toward the beginning of that ordeal, a doctor had decided that my issue required major surgery involving the removal of an organ. Less than one day before the scheduled surgery, the doctor decided to do "one more test" for an easily treatable condition. As it turned out, he had misread a previous doctor's note suggesting a possible diagnosis, as a dismissal of the diagnosis. I'll never know whether the confusion was due to poor handwriting or poor attention to detail, but I feel lucky that the error was caught in time. I met multiple people during my numerous, lengthy visits whom I suspect were not as lucky.

tokenadult 14y ago

From the submitted article: "Nothing makes hospitals shape up more quickly than this kind of public reporting. In 1989, the first year that New York's hospitals were required to report heart-surgery death rates, the death rate by hospital ranged from 1% to 18%—a huge gap. Consumers were finally armed with useful data. They could ask: "Why have a coronary artery bypass graft operation at a place where you have a 1-in-6 chance of dying compared with a hospital with a 1-in-100 chance of dying?" "Instantly, New York heart hospitals with high mortality rates scrambled to improve; death rates declined by 83% in six years. Management at these hospitals finally asked staff what they had to do to make care safer. At some hospitals, the surgeons said they needed anesthesiologists who specialized in heart surgery; at others, nurse practitioners were brought in. At one hospital, the staff reported that a particular surgeon simply wasn't fit to be operating. His mortality rate was so high that it was skewing the hospital's average. Administrators ordered him to stop doing heart surgery. Goodbye, Dr. Hodad." So we have a known model that improves results. Let the patients who decide which hospitals to visit know beforehand how hospitals compare in getting good results for patients. Give patients power to shop. That provides incentives for hospitals to do better, and nudges hospital managers to do what is necessary to win the trust of informed patients. This kind of reform would be very good to apply to schools as well. Already, one state in the United States that is conspicuous among all fifty states in educational achievement (the state I live in) allows all residents of the state to enroll in the public schools of ANY school district anywhere in the state. (The school district I live in has inbound open-enrollment students from the geographical territories of forty-one other school districts.) In general, the power to shop is the incentive factor to bolster by government regulation, letting each consumer decide what trade-offs are important. That works considerably better in driving improvement than regulating outcome goals, and better still than regulating inputs into the provision of the important service being regulated.

jonah 14y ago
Real data and informed consumers are a very valid way to promote improvement through "competition". Often times though, that's not enough as is the case in LA right now where patients are being prevented from using the best doctors: Two of the most prestigious names in Southern California healthcare — Cedars-Sinai and UCLA — are getting shut out of a major insurance plan for being too expensive. In a bold cost-cutting move, Anthem Blue Cross has eliminated doctors affiliated with the hospitals from a health plan offered to about 60,000 employees and dependents at the cash-strapped city of Los Angeles. The city opted for Anthem's plan because it will save $7.6 million in annual premiums next year by excluding physicians from the two institutions known for tending to the Southland's rich and famous. About 2,200 city workers and family members are expected to lose access to their doctors under the plan. This dramatic step shows that even some of the most-respected names in medicine can't get by on reputation alone at a time when the U.S. is grappling with a $2.6-trillion healthcare bill annually. Major hospitals and medical groups face growing pressure to justify their charges. And employers increasingly are willing to risk the ire of workers by cutting popular providers to clamp down on costs. - http://www.latimes.com/business/la-fi-hospital-costs-20120921,0,2292633.story http://www.latimes.com/business/la-fi-hospital-costs-2012092...

Riesling 14y ago

The current state of medicine is extremely frightening. Note 1: My comments here relate to the German health system, with which I am most familiar with, but I assume that other systems work similar, if not less efficiently. In my opinion, there are many other problems in the broad field of medicine, but the following two points could be resolved with the support of IT, so I will confine my remarks to those. 1. Plausibility checks Virtually no plausibility checks will be carried out in todays hospitals. Often conflicting drugs are prescribed, which produce uncomfortable side effects. One should start to make all medications and treatment measures subject to automatic (computer based) plausibility checks. This would also lead to a cognitive relief of the clinical staff. 2. Statistical evaluations (data mining) The lack of inadequate statistical analysis is another concern. Germany has begun to build a national cancer database only this year. One can only imagine what valuable information is hidden in those statistics and have been missed up to this day. Imagine an international database in which all patients who are admitted as an emergency to the hospital are captured statistically. This data could be stored completely anonymous. The only thing of importance would be the provision of relevant laboratory values and the patient's symptoms described in the context of the (verified) final diagnosis. Such a system could support the finding of completely new knowledge (data mining) and support the doctor in finding the right diagnosis. And of course the hospitals need strong incentives to implement these measures. Which is why I support the author's call for absolute transparency.