Medical Errors: Much Ado About Numbers

Link to Source

The now-famous Institute of Medicine (IOM) Report, To Err is Human which was released in 1999 created a huge furor and led to a large number of quality improvement initiatives with increased funding for quality improvement initiatives designed to reduce medical errors. Arguably, the major reason for such a drastic response from the US Congress and other Governmental and Non-Governmental Organizations is that the report stated that, " At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented, according to estimates from two major studies". Surely, these numbers are indeed headliners and you can imagine the headlines from the major news agencies when the report was released!

Link to Source

It is worth noting that the report emphasizes that the major problem is not a human problem, but a systemic problem. This means that most problems are not caused by problems with humans but that somehow, the systems are not quite structured correctly.

Two groups of scholars debated the issues related to the findings of the two studies cited by the report: the Harvard Medical Practice Study and a 1992 Study done in Colorado and Utah. In the first argument as published in JAMA in September 2000, Clement McDonald, Jonathan Weiner and others argued that the IOM's numbers are false. They argued that the rate of medical errors are not statistically accurate because among other things, there was no comparison group to enable us calculate the "excess mortality" and the data did not take into consideration, the baseline risks of death, the study design was not able to imply causality and other interesting observations. Bottom-line, the numbers are not that high.

In a rebuttal published in the same journal, Lucian Leape argued that the numbers are actually an under-estimation for many reasons including the fact that the selection criteria made it difficult to detect as many errors as there are in the real world and other interesting arguments. Barbara Starfield in her own study which was also published by JAMA estimated a much higher number, stating that as much as 225,000 deaths occur every year from iatrogenic causes in the United States in essence, agreeing with Leape.

My conclusion, which was also alluded to by Leape is that the focus should not be on the numbers but on the fact that this is a serious issue which needs to be tackled for the good of everyone. By my own estimates, almost one in 5 people know someone who has been a victim of a medical error in one way or another. Whether these errors lead to harm is another matter altogether. Let us focus on reducing the probability of errors been committed rather than on spending time on epidemiological and statistical arguments to argue how "statistically significant" the differences in our estimates are. Granted, this is an old question, but I wanted to put my voice out there. I am curious to know if the numbers have reduced over the years due to the measures instituted by Congress. I will explore this and post my thoughts at a later date.

Nigeria's Health Insurance Scheme: Can Universal Coverage be Achieved by 2015?

Some Advice for Daily Living

I debated for a while about posting some "non-technical" content on my blog but in the light of some recent unfortunate events in my life, I have decided to post it anyway, in honor of my late cousin and brother, Akinwale Okebukola. I miss you so much. Rest in Peace.


This article was culled from Baz Luhrman's song, "Everybody's Free" and from Mary Schmich's now-famous article in the Chicago Tribune which can be read here. I have made a few modifications at my discretion. Please enjoy it and let me know your thoughts

My dear friends, "Wear sunscreen"

If I could offer you only one tip for the future, "sunscreen" would be it.

The long-term benefits of sunscreen have been proved by scientists, whereas the rest of my advice has no basis more reliable than my own meandering experience.

I will dispense this advice now:

Source: click

Enjoy the power and beauty of your youth.

Oh, never mind.

You will not understand the power and beauty of your youth until they've faded.

But trust me, in 20 years, you'll look back at photos of yourself and recall in a way you can't grasp now how much possibility lay before you and how fabulous you really looked.

You are not as fat as you imagine.

Don't worry about the future.

Or worry, but know that worrying is as effective as trying to solve an algebra equation by chewing bubble gum.

Source: click

The real troubles in your life are apt to be things that never crossed your worried mind, the kind that blindside you at 4 pm on some idle Tuesday.

Do one thing every day that scares you.

Sing

Don't be reckless with other people's hearts.

Don't put up with people who are reckless with yours.

Floss.

Don't waste your time on jealousy.

Sometimes you're ahead, sometimes you're behind.

The race is long and, in the end, it's only with yourself.

Remember compliments you receive.

Forget the insults.

If you succeed in doing this, tell me how.

Keep your old love letters.

Throw away your old bank statements.

Source: click

Stretch

Don't feel guilty if you don't know what you want to do with your life.

The most interesting people I know didn't know at 22 what they wanted to do with their lives.

Some of the most interesting 40-year-olds I know still don't.

Maybe you'll marry, maybe you won't.

Maybe you'll have children, maybe you won't.

Maybe you'll divorce at 40. 

Maybe you'll dance the funky chicken on your 75th wedding anniversary.

Whatever you do, don't congratulate yourself too much, or berate yourself either.

Your choices are half chance. So are everybody else's.

Enjoy your body.

Use it every way you can.

Source: click

Don't be afraid of it or of what other people think of it.

It's the greatest instrument you'll ever own.

Dance

Even if you have nowhere to do it but your living room.

Read the directions, even if you don't follow them.

Get to know your parents.

You never know when they'll be gone for good.

 Be nice to your siblings.

They're your best link to your past and the people most likely to stick with you in the future.

Understand that friends come and go,

but with a precious few you should hold on.

Source: click

Work hard to bridge the gaps in geography and lifestyle, because the older you get,

the more you need the people who knew you when you were young.

Travel

Accept certain inalienable truths:

Prices will rise.

Politicians will philander.

You, too, will get old.

And when you do, you'll fantasize that when you were young, prices were reasonable, politicians were noble, and children respected their elders.

Respect your elders.

Source: click

Don't expect anyone else to support you.

Maybe you’ll have a trust fund.

Maybe you'll have a wealthy spouse.

But you never know when either one might run out.

Don't mess too much with your hair or when you're 40 it will look 85.

Careful whose advice you buy, but be patient with those who supply it.

Advice is a form of nostalgia.

Dispensing it is a way of fishing the past from the disposal, wiping it off, painting over the ugly parts and recycling it for more than it's worth.

But trust me on the sunscreen.

Source: click

Brother and sister together we'll make it through,

His Spirit will guide us through.

I know that you're hurting but I'll be there just helping you out whenever I can...

The Baldrige National Quality Award Winners- The Role of Information Technology

I will be making a presentation about the Baldrige National Quality Award next week. This is similar to the Deming Prize which is given to Japanese companies for innovation in quality delivery in organizational processes and outcomes. The Baldrige Award is given annually by the President of the United States (although the Vice President handed out the last one) to companies in the US in various sectors including healthcare. It is named in honor of a former Secretary of commerce, Malcolm Baldrige, whose picture appears below.

Malcolm Baldrige. (Source nist.gov)

The question I want to explore is, "What is the role of information technology in the day-to-day running of companies who have won the Baldrige Award. Does IT give them any edge over other competitors?" Health Care IT News discussed the advantage IT gave 2010 Health Care Award Winner the Good Samaritan Hospital, in their blog which can be accessed by clicking here. I will discuss its role in the 2011 winners, AtlantiCare Hospital and Heartland Health in my next post.

Watch this space!

Improving Health Care Quality Through Electronic Health Records

In this post, I would like to share a video I watched recently which examines the use of Electronic Health Records (EHRs) to improve quality of healthcare. The video- posted by HRSA- is fairly long but also very informative. Enjoy it.

Can Information Technology Improve Readmission Rates?

Source: Vital Partners

Many factors have been found to be associated with readmissions according to a study done by Allison Nudge and colleagues in Australia.  The authors showed a correlation between readmissions rate and factors like co-morbidities, nutritional status and mood  of the patients. They studied patients with chronic conditions who had two or more admissions in six months. The rate of readmissions is an important issue for hospital administrators and policy makers because of their relationship to increasing costs, especially in health systems that use the DRG (Diagnosis Related Group) payment system like the United States.

It is within this backdrop that I discuss the ability of information technology to help solve or at least, reduce this problem. Carol Everhart, in an article published online in Pharmacy Choice, opined that hospitals should pay attention to the particular reasons why individual patients are returning to the hospital after being discharged home and not focus solely on aggregated hospital data.

How can hospitals do this? It is obvious as shown in Nudge's paper, that one readmission drastically increases the risk for repeat readmissions as well as other factors she described. Granted, there is not much that can be done by physicians without electronic medical records and so, my suggestions are going to be based on situations where there are clinical decision making tools like CDSS (for an understanding of this, see my previous posts).

Is it possible to write a program such that the presence of these risk factors for readmissions are coded in the electronic medical records and a warning system is put in place such that the physician in charge is able to activate an anti-readmissions protocol which can help reduce the likelihood of another readmission? By all indications, this is possible and I am almost sure that this is been put in place somewhere. If you have an idea of where this occurs, please let me know.

We would do well to note that many factors that predispose to readmissions are not known at the time of discharge and consequently, cannot be predicted. However, most of them are known and the patient can benefit from these interventions which can also help the hospital save costs. Will these technological innovations be useful for preventing readmissions that are due to nutritional problems or mood/ psychological imbalances as discussed by Nudge et. al? I guess we just have to keep our fingers crossed.

In my next post, I will report such technological innovations and where they are being put into use.

Readmissions is a very exciting area that I look forward to exploring going forward.

Technology to Improve Patients' Adherence to Medication

I will like to share with you as promised, a technology based initiative that I believe will help improve patient adherence. This program will involve a combination of periodic text messages or e-mails informing patients of the time to take their medication coupled with an alarm fitted on the medication packet that can only be stopped after the patient takes the pill.

Description: the pills will be in an electronic container that will beep like an alarm clock at the time the drug is due to be taken. The alarm only stops when the pill is removed. At the same time, a text message or email will be sent daily to remind the patient. For multiple pills, a computer program can be used.

The initiative has two potential disadvantages: one is that the patient can develop alert fatigue, that is, gets “numbed” to the alerts and might develop an aversion to the system. This can only be solved by a patient education program which must run concurrently. The other is that the system does not actually tell if the patient takes the medication, it only tells if the pill was removed.

Options: The patient will be placed in the program by default but can only opt-out if the physician decides that the patient is not at risk of default, evidenced by writing a letter of undertaking on behalf of the patient.

The mechanism involves active choice by the patient. The patient can only opt out after showing a record of adherence for a period of time, say 3 months after which the doctor can vouch for him/her.

Consequences of default were described by Martin et al. (2005) and include development of worse symptoms, progression of disease to more fatal stages, higher cost of treatment, increased risk of infecting others, time wasting seeking treatment, inefficiency of health systems etc

The program does not preserve the choice of the patient to a large extent. However, with the concurrent patient education program, the patient can be made to understand that the risk of default are too great and that if he complies, he does not have to get an alarm ring and he can be out of the program after 3 months if he complies. The program would be cost effective in that it would save the health system from bearing the cost burden of non-adherence

Reference

Leslie R Martin, Summer L Williams, Kelly B Haskard  and M Robin DiMatteo (2005). The challenge of patient adherence; Journal of Clinical Risk Management, September; 1(3): 189–199.