Archive for September, 2013|Monthly archive page

Chocolates and patient safety

In High Reliability Orgs, Normal Accident Theory, Patient Safety, Resiliency on September 22, 2013 at 3:17 pm

From Rosemary Gibson:

How Overtreatment and High Volume Health Care is Making Patient Safety a More Distant Reality by Rosemary Gibson

“This past week at the National Health Care Quality Colloquium I showed the classic “I Love Lucy” chocolate factory video during a presentation. The laughter was audible and the point was made: when the pace of work speeds up, work-arounds and cutting corners are inevitable. Employees tell the boss everything is fine –when its not.

In a health care system riddled with defects where doctors and nurses are required by health care executives to work at a faster pace, the number of adverse events — and patients harmed — will increase. High volume health care and productivity targets are a toxic mix. … Read and’s funny but not…
The Chocolate scene on you tube

“They killed my patient then tried to hide it!”

In adverse events, human error on September 22, 2013 at 5:54 am

Scroll down to read a Blog post from a Boston area MD. I think somehow hospital administrators/boards justify this type of behavior in the name of the greater good (eg. keeping hospitals open and people in awe of their ability to heal..see Placebo). I think many healthcare workers have had their stories “changed” during investigations in which a hospital might have liability and have certainly been told things by lawyers that are less than the truth. Been there.

Let’s remember, the anesthesiologists involved doubtfully went to work that day planning to kill a pregnant woman! I wish the Md in this post (and the hospital) had been a little more understanding about human error. An admission of error followed by apology, full disclosure and just compensation by the hospital could have spared the family the trauma of a lawsuit and prevented the author of the following blog post from harboring angry feelings so many years later.

Scarier than Halloween: new estimates of harm

In adverse events on September 21, 2013 at 2:37 pm


Journal of Patient SAfety: A_New,_Evidence_based_Estimate_of_Patient_Harms

Objectives: Based on 1984 data developed from reviews of medical records of patients treated in New York hospitals, the Institute of Medicine estimated that up to 98,000 Americans die each year from medical errors. The basis of this estimate is nearly 3 decades old; herein, an updated estimate is developed from modern studies published from 2008 to 2011.

Methods: A literature review identified 4 limited studies that used primarily the Global Trigger Tool to flag specific evidence in medical records, such as medication stop orders or abnormal laboratory results, which point to an adverse event that may have harmed a patient. Ultimately, a physician must concur on the findings of an adverse event and then classify the severity of patient harm.

Results: Using a weighted average of the 4 studies, a lower limit of 210,000 deaths per year was associated with preventable harm in hospitals. Given limitations in the search capability of the Global Trigger Tool and the incompleteness of medical records on which the Tool depends, the true number of premature deaths associated with preventable harm to patients was estimated at more than 400,000 per year. Serious harm seems to be 10- to 20-fold more common than lethal harm.

Conclusions: The epidemic of patient harm in hospitals must be taken more seriously if it is to be curtailed. Fully engaging patients and their advocates during hospital care, systematically seeking the patients’ voice in identifying harms, transparent accountability for harm, and intentional correction of root causes of harm will be necessary to accomplish this goal.

Neuroscience Saturdays: Placebo “I shall please”

In Neuroscience on September 21, 2013 at 2:20 pm

From:American Physiological Society

“For many years placebos have been used for the validation of therapies, but they have also traditionally taken as an example of the powerful interaction between mind and body with associated commentary research appearing in psychology literature. Dr. Benedetti’s research is aligned with the current state of placebo research, a complex field of investigation which ranges from psychology to psychophysiology, from pharmacology to neurophysiology, and from cellular/molecular analysis to modern neuroimaging techniques.

Dr. Benedetti’s research methodology employed in this article transcends the traditional division between psychology, the study of the mind and how it works, and biology, the study of all living things. This article clarifies the research conducted to identify the relationship between pharmacological treatments administered to the patient and the role of the mind in the overall patient health. In addition, it clarifies the interaction between psychological processes and the many physiological functions of the human body.
This new discipline acknowledges that placebos and placebo responses with their wide range of physiological responses involving numerous mechanisms across a number of conditions, systems, and interventions represent an active field of neurobiological research. With that, Dr. Benedetti, using biochemical, cellular and physiological tools, aptly summarizes research new findings on describing the placebo effect on psychology and biology and their impact on the doctor-patient relationship. Among the issues discussed in detail are: ■There is no one “the placebo effect.” There are different mechanisms in play across a variety of medical conditions and therapeutic interventions. For example, a placebo effect takes place because there is expectation. The patient expects a therapeutic benefit, and this kind of expectation actually has an effect on the brain and the body.
■The connection between expectation and real improvement that may occur is due at least to two mechanisms. The first may be a reduction of anxiety. The second is between expectation and the activation of a reward mechanism by the region of the brain known as the nucleus accumbens (which also governs pleasure, reinforcement learning, laughter, addiction, aggression, fear, impulsivity and the placebo effect.)
■ When a treatment is given to a patient, be it a placebo or real, it is administered in a complex set of psychological states that vary from patient to patient and from situation to situation. For example, when a placebo is given to relieve pain, it is administered along with stimuli which tell the patient that a clinical improvement should be occurring shortly. These stimuli can include the color and shape of the pill, patient and provider characteristics and the healthcare setting.
■Recent research has revealed a reduced efficacy of drugs when they are administered covertly to the patient. In fact, if the placebo/expectation component of a treatment is eliminated by means of a hidden administration (unbeknownst to the patient), the psychological component of the therapy is absent as well.

For physicians, psychologists, and health professionals these and other recent findings found in Dr. Benedetti’s article can foster enhanced understanding of how their words, attitudes, and behaviors impact on the physiological profile of their patients’ brains.” Read more:

Stamp out unsafe processes

In Root cause analysis, safety on September 20, 2013 at 8:18 am

From Nancy Leveson’s site at MIT

Applying System Engineering to Pharmaceutical Safety by Nancy Leveson, Matthieu Couturier, John Thomas, Meghan Dierks, David Wierz, Bruce Psaty, Stan Finkelstein. Journal of Healthcare Engineering, Sept. 2012.

While engineering techniques are used in the development of medical devices and have been applied to individual healthcare processes, such as the use of checklists in surgery and ICUs, the application of system engineering techniques to larger healthcare systems is less common. System safety is the part of system engineering that uses modeling and analysis to identify hazards and to design the system to eliminate or control them. In this paper, we demonstrate how to apply a new, safety engineering static and dynamic modeling and analysis approach to healthcare systems. Pharmaceutical safety is used as the example in the paper, but the same approach is potentially applicable to other complex healthcare systems.
One use for such modeling and analysis is to provide a rigorous way to evaluate the efficacy of potential policy changes as a whole. Less than effective changes may be made when they are created piecemeal to fix a current set of adverse events. Existing pressures and influences, not changed by the new procedures, can defeat the intent of the changes by leading to unintended and counterbalancing actions by system stakeholders. System engineering techniques can be used in re-engineering the system as a whole to achieve the system goals, including both enhancing the safety of current drugs while, at the same time, encouraging the development of new drugs.

Read this an other papers about this new model of incident investigation here

Neuroscience Saturdays: Want to see? skip the fish

In Neuroscience on September 15, 2013 at 7:52 pm

The health of healthcare workers may affect patient safety in various ways. Accurate vision is necessary for examining patients, reading medication packages, reviewing diagnostic films…etc
Can eating fish compromise vision?

“Researchers are studying the potential effects of low level chronic exposure to methylmercury, which is of global concern due to methylmercury presence in fish, but the message that I want to get across is that such exposures may negatively affect vision. Our study clearly shows that we need more research into the direct effects of methylmercury on the eye,” Korbas concluded.”

Read more
“Human populations experience widespread low level exposure to organometallic methylmercury compounds through consumption of fish and other seafood. At higher levels, methylmercury compounds specifically target nervous systems, and among the many effects of their exposure are visual disturbances, including blindness, which previously were thought to be due to methylmercury-induced damage to the visual cortex”

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