Patient Safety

Time to Write Congress re: The Checklist Debacle

Thanks to all of you who have taken the time to write, blog, and rant about the OHRP's horrific decision to shut down the Hopkins-Michigan ICU checklist study, a decision that threatens the future of quality improvement and safety efforts in American healthcare. Today, the major hospital-based societies – representing over 100,000 clinicians and leaders – sent a powerful letter to HHS Secretary Leavitt, asking that he stop the madness. (For background info on this case of massive regulatory hyperplasia, see my prior blogs here and here.)The letter, co-signed by the Society of Hospital Medicine, the Society of Critical Care Medicine, the American Thoracic Society, the American Association of Critical Care Nurses, and the American College of Chest Physicians, is here. And by clicking here, you'll be taken to SHM's spiffy Legislative Action Center, which makes it easy to write to your Senator and Representative. I'm betting that the OHRP…

Is Medicare’s “No Pay for Errors” Plan a Good Idea?

In this month’s issue of the Joint Commission Journal of Quality and Patient Safety, I (with UCSF’s Adams Dudley and the American Hospital Association's Nancy Foster) tackle this provocative question. The answer may surprise you: yes (probably). The devil will be in the details.I hope you’ll have a chance to read the full article (the Joint Commission Journal has made it freely available to readers of AHRQ Patient Safety Network, so you can get it here). But the bottom line is this: in our judgment, a policy of withholding payment for adverse events is reasonable when the following criteria are satisfied:Evidence demonstrates that the adverse events in question can largely be prevented by widespread adoption of achievable practices.The events can be measured accurately, in a way that is auditable.The events resulted in clinically significant patient harm.It is possible, through chart review, to differentiate adverse events that began in the hospital…

Can Medical Errors Be Funny? You Betcha.

All medical mistakes are problematic. A few are truly tragic. But every now and then, a medical error comes along that is downright hilarious. From AHRQ WebM&M, the case-based Web journal I edit for the federal government, here are two of the latter kind. They are a hoot.We published the first about three years ago and called it “Allergy to Holter”:A 52-year-old man was admitted for palpitations and chest pain. As part of the evaluation, on hospital day 4 the patient was sent to the cardiac clinic to start a continuous recording of his electrocardiogram via Holter monitor.Since the patient was ambulatory and had gone for other tests on his own, he was told to go to the cardiology clinic for a check-up of his heart rhythm. He was handed a "Request for Consultation" form, on which there was only one word: "Holter." The form did not state the patient's…

How Clinical IT is Transforming Hospital Care – For Better and Worse

My friend Mark Smith, who runs the California HealthCare Foundation, once wryly observed, “Have you ever noticed that the doctors who talk about how much fun primary care is only practice it one afternoon a week?” I may have become the hospitalist version of Mark’s Ivory Tower internists, but I’ll take my chances.I just finished a two-week stint on the wards. I loved it, but I only do clinical ward attending a couple of months per year – I realize that those of you who see patients all the time may not be quite as jazzed. Nevertheless, one of the advantages of doing clinical medicine sporadically is that it leaves me well positioned to notice changes in clinical care, for the same reason that people who see your kids every six months are struck by their growth spurts.Today, some thoughts on information technology and its impact on day-to-day hospital care.…

Did I Violate Federal Regulations Today? (I Hope So)

The patient safety and quality movements are precious and fragile. Just as IOM reports I and II spawned these modern, life-saving revolutions, the Federal shutdown of the Hopkins/Michigan checklist program may help extinguish them. After all, Tipping Points can tip both ways. I laid out the issues in this prior post. Those of you who know me know that I am anything but a rabble-rouser – I have the affliction of seeing both sides of every issue. But, as someone who cares about the lives of patients, this one gets me PISSED. Apparently, many of you feel the same way – particular thanks to Paul Levy, Charlie Baker, Maggie Mahar, Jim Sabin, AHA Prez Rich Umbdenstock, and of course Atul Gawande. After many of you wrote, blogged, and otherwise bellowed, “I’m Mad As Hell And I’m Not Gonna Take This Anymore,” the Office for Health Research Protection issued an Orwellian…
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