Improve the safety of your patients… share your ideas!

José Joaquín Mira

"But, if you don't know how this goes...!" "What are you in for?" "Shut up, you're better!" Expressions like these are common. They modulate the culture of our organizations and, although we do not give them excessive significance, they condition our behaviour. I don't know if it has happened to you, but sometimes we have the feeling that it is better to remain silent than to speak. Sometimes, the fear of being disliked, receiving a bad response, or receiving a reprimand causes us to keep quiet. In the workplace, there are hierarchies, unwritten rules, customs, and group dynamics that determine when and how things are done and what should and should not be said. But this way, the quality of care will never improve and patients will have a higher risk of suffering an adverse event. The culture of the organization contributes to speaking up or shutting up. Individual differences do the rest.

The pandemic of medical errors

Salvador Casado

George Ștefănescu - Cosmos, 1992

The death of a young person from undiagnosed cancer often comes as a shock to those around them. In recent weeks there has been a lot of controversy on social networks following the death of the journalist Olatz Vazquez, who documented her illness to the end with photos, which has encouraged me to reflect on medical error, to be self-critical of my own and to try to make proposals from a broad vision that includes all the actors. The Sarscov2 pandemic has caused another pandemic of unavoidable medical errors both by action and, above all, by omission, because the collapse of health systems around the world has caused them to stop attending sufficiently to other pathologies for many months. In the following text I approach the subject from the point of view of a healthcare professional who tries to explain it to his patients and colleagues and not from a technical approach, for which I provide a list of suggestions for further reading at the end.

Patient safety and iatrogenesis

Andreu Segura

Among the most important public health problems today, the harmful effects associated with clinical and health care practice stand out, the relevance of which is unquestionable given their impact and, above all, their aetiology. Hence the development of the so-called patient safety strategy, the purpose of which is to limit as much as possible the damage that medical and health care interventions can cause provided that such damage can be avoided.

From the humanisation of medicine to the dehumanisation of professionals

Gustavo Tolchinsky

The well-being of doctors is an issue that has a direct impact on the quality and quantity of care that healthcare systems can deliver to society. You only need review several of the entries of recent months and certain articles that even quantify the cost and waste that burnout implies for healthcare organisations. As has been shown in these articles, organisational factors, workloads, alienation from the values of organisations and professionals, the autonomy of professionals to manage their work, and even the type of clinical information management programs and their usability affect professional well-being.

Centralisation of complex surgery: clear, obscure and proposals

@varelalaf

A large group of European and North American surgeons have published in Annals of Surgery a review of the difficulties of centralising complex surgery around the world. The complex issue has multiple actors, starting with governments and respective funding models and continuing by the hospitals, the doctors involved and their corresponding scientific societies. It is surprising, however, that patients rarely appear in such discussions.

Raiders of lost clinical reasoning

In a previous post, "Against manual medicine," I analyzed the concern of two internal physicians at Brigham and Women's Hospital for the excesses of manual medicine in their book When doctors don’t listen. Avoid misdiagnoses and unnecessary tests. on this same subject I want to talk about Jerome Kassirer, John Wong and Richard Kopelman, three authors who in 1991 published Learning Clinical Reasoning, a reference work that laid the foundations of clinical reasoning through the inferential process of hypothesis generation diagnosis, its subsequent refinement with the elaboration of a diagnosis of work, the sustained request of complementary tests, the management of Bayes' theorem, the causal models, the diagnostic verification and the taking of therapeutic decisions. Twenty years later, the same authors published the second edition of the book, and in their presentation said they were forced to update it because in recent times, the practice of medicine had undergone very profound changes. According to them, rapid triage in emergencies and reduction of hospital stays are forcing doctors to be less contemplative and they are often seen short-circuiting the diagnostic process, or by cutting out minutes of time spent in interviewing or exploring where they try to compensate by quickly sending patients to perform diagnostic tests. This obsession with the performance of physicians is detrimental to the reflection on what has been learned in the observations made and the establishment of a qualified relationship with the patient. The authors state that the diagnostic process, as it was known, has been replaced by "take a look and ask for a CT".

On the subject of continuity of care in hospitals

Last week we debated how the longitudinal continuity of primary care affects the comings and goings of chronic patients to emergency services. Along this line, I would like to explore the difficulties that hospitals have in guaranteeing ongoing health care services especially at night and at weekends, and how this problem weighs on services when taking care of the most vulnerable groups.

Imagine that a frail person enters a hospital due to acute decom-pensation, according to the known evidence, a global geriatric eva-luation and an individualized therapeutic plan should be deve-loped in agreement with the primary care team, if the desired outcome is to have a reasonable chance of returning home as soon as possible and in the best possible condition. The problem originates in that the hospitals, not even the best of them, are able to give a continuous response to patients as described, since the usual medical equipment usually offers a continuous coverage of only 27% (From a 5 day week of 8 to 5). What happens in the remaining 73% of time (evenings, nights and weekends)? As our imaginary patient, although you would enjoy medical coverage on duty, the service you will receive is very likely far from guaranteeing the continuity necessary for the fulfilment of your personalized plan.

Against cookbook medicine

"How can modern medicine be so dehumanized?" is a question posed by Dr. Leana Wen and Dr. Joshua Kosowsky in “When doctors don’t listen”. According to them, with a few exceptions, the practice of medicine is subjugated by the dictatorship of guidelines, algorithms, codes, protocols and rules. "Cookbook medicine" they call it. Everyone is aware that many requested tests are unnecessary and that many people are subjected to anxiety induced by the prescribed manual diagnostic processes to rule out infrequent pathologies. The theory of the book is based on the fact that the process to arrive at a diagnosis is complex, requires an interview in which the patient can frankly express the story of what is happening to him, a physical examination according to the hypotheses that arise and a clinical reasoning participated by the patient himself; all this, very far from a manual practice.

The slow progress of clinical safety, a problem of "many hands"

Cristina Roure

In this section we usually discuss overdiagnosis and overtreatment, but today we will talk about the difficulty in achieving safe care environments for patients.

Some will remember the publication in the year 2000 of the report “To err is human. Building a safer Health System” by the Institute of Medicine's Quality Care, which created a big impact in the media due to the alarming figures of deaths caused by medical errors in the USA. (1). Since then, a lot of work has been done in order to improve patient safety, and a lot of progress has been made for the dissemination of the clinical safety culture, and a great deal of effort and resources have been devoted to the implementation of safe practices for reducing the risk of medical errors.

Coronary Bypass and Hemodynamics: the amount matters

In the article "Comparing hospital performance within and across countries: an illustrative study of coronary artery bypass graft surgery in England and Spain", signed by a Spanish-English team in which Sandra García Armesto (IACS) and Enrique Bernal (REDISSEC) participated, it was concluded that the Spanish hospitals of the study operated in general with a smaller number of cases than the English (it was coronary bypass). Therefore, it is suggested that the number of cases intervened should be a tracer that could explain why mortality from this process is twice as high in Spain as in England.

European Collaboration for Healthcare Optimization (ECHO) is a European network of administrative databases for the analysis of clinical practice variations. In the following article: "Hospital Surgical Volumes and Mortality after Coronary Artery Bypass Grafting: Using International Comparisons to Determine Safe Threshold", carried out by almost the same authors as the previous one, based on data from the ECHO project, confirms that for interventions of coronary bypass there is a clear relationship between volume and mortality and concludes that the minimum limit of interventions of a cardiac surgery team, if you want to safeguard the safety of patients, should be 415 per year. In the following graph (from the previous article) it is observed how the Spanish hospitals that participated in the study (dark spots), generally underwent fewer coronary bypasses (many did not reach 200) and showed greater mortalities.

Hospitalizations and patients’ experiences

Peter Pronovost, a renowned expert in clinical quality and safety, argues that it’s a mistake for hospitals to focus on patient satisfaction surveys and states that instead it would be more helpful to ask selected patients what proposals they would make in order to improve the hospitalization experience. For example, one of the people Johns Hopkins chose for this assignment was Podge Reed Jr., a double lung transplant patient who had amassed six hospitalizations, two surgical and four medical, eight anaesthesia outpatient procedures, more than one hundred visits to appointments and 700 laboratory tests. With this curriculum, the hospital felt that Mr.Reed should be a person with a clear opinion.

In the article, Jane Hill, Johns Hopkins’ Patient Relations Director, says that most hospitalised people, although appreciating the technical quality of services, also ask to be treated with kindness and care. Not surprising, given that being bedridden in a hospital is not a pleasant experience for anyone. As a result of patients' contributions, Jane Hill has developed a Decalogue that should be read as a basis for transforming hospitalization rooms, on one hand from the perspective of tasks, functions and competencies and on the other hand, with a view of patients’ experience.

The diagnostic process and medical errors

The past 15 years, since the publication of "To Err Is Human" report, has seen a great deal of progress in projects that promote patient safety, especially in programs such as increasing hand washing, identifying patients, surgical checklists or changes in nursing care, but on the other hand the diagnostic process continues to be a matter almost exclusive to medical work although it’s known that this is a very sensitive area for the safety of patients. This new report from the National Academy of Medicine (formerly Institute of Medicine), "Improving Diagnosis in Healthcare," is a follow up document to the aforementioned one, specifically focused on diagnostic errors.

The report defines the diagnostic error as the failure to obtain a detailed, timely explanation of a health problem. Experts have also included in the definition the physician’s inability to know how to explain the diagnosis to the patient. According to the report, diagnostic errors would have an incidence on medical consultations of 5%, accounting for 10% of deaths, 6-7% of adverse reactions in hospitals, as well as the leading cause of litigation in the health area (the figures correspond to the US).

Claims for adverse events: a predictive algorithm

Glòria Galvez

Strategies focused on encouraging patients' participation in the health system, and more specifically those related to quality and safety, have seen some a great deal of progress in recent years. A person-centred health system should promote active patient participation and use the complaints handled by patient care services as a specific instrument of participation. When the patient expresses the disagreement with the attention received, he or she is providing us with valuable information that is very useful in the continuous monitoring and improvement of quality. It doesn’t seem that there are many health institutions that use complaints and claims as a learning tool, but they rather use it as a mere descriptive statistic in the annual report of the organization, thus losing the opportunity for improvement that their analysis and monitoring would provide.

Dr. Gallagher, who, as someone with extensive experience in issues related to patient safety and disclosure of medical errors, has published an article in BMJ Quality & Safety: “Taking complaints seriously: using the patient safety lens” in which he proposes analysing complaints from a point of view of patient safety and treating them as if they were adverse events, in the same way as with the more traditional ones, such as those related to safe surgery or the appropriate use of medications. This is an innovative approach that will provide relevant information when proposing proactive interventions.

Basic instruments for clinical management

In preparing this post I have chosen nine references which, in my opinion, have been milestones in the development of methodologies and tools that have shaped clinical management as we understand it today. To make it more understandable, I have framed these milestones in 5 relevant periods: the introduction of the concepts of quality in the 60s, the protocols in the 70s, the consensus in the 80s, the evidence of 90s and the safety of patients in the first decade of this century.

Modern clinical management: the basics

In recent decades, clinical management has had a couple of conceptual disruptions that have generated interest in the welfare act as an object of study. The first was when, in the early 90s a group of epidemiologists moved clinical epidemiology from the academy to the consultation and developed evidence-based medicine; and the second came when governments and health professionals became knowledgeable about the clinical work’s ability to do harm. The "To err is human" from the Institute of Medicine report in late 1999 was the turning point of patient safety programs. Now, in the second decade of the century, starting from those two fundaments (security and evidence), all the interest is in knowing what is the value that clinical practice brings to the health of people.

The conceptual foundations of modern clinical management

Hospitals: 10 necessary structural reforms

Hospitals are structures that generate a powerful influence on the overall health system. Their effectiveness in the resolution of certain acute diseases, especially surgical, gives them a great social prestige. This fact should not, however, hide two structural problems that are burdening their perspective:

a) The first problem is internal. Bureaucracies themselves are showing signs of fatigue and this affects the quality of services, especially in the safety of admitted patients.

Hospital wards (2): occupation, weekends and safety

In the last Monday’s post, I was referring to the organizational quality, the provision for the medical guard and the coordination of professionals with the clinical safety of patients, and this second part of the same subject of hospitalization wards, I was left with a couple of things to deal with, also related to the quality of care: the stress caused by the large workload and the lack of services during the weekends.

The high occupancy of the wards increases mortality

A group from the University of Cologne, with the collaboration of Cambridge, has conducted a study in 83 German hospitals with more than 80,000 patients with pathologies of risk and have concluded that the tipping point for a hospital ward is 92,5%, occupation, a figure from which, the chaos inherent in the situation created by the excess patients, generates a significant increase in mortality.

"If a hospital regularly works above the tipping point, says professor Stefan Scholte's in the Cambridge University blog, you can bet that it has a structural quality problem, but what we need to be wary of, is those hospitals reaching the tipping point occasionally but repeatedly, generating risk situations for patients who are not normally detected by the aggregate statistics."

Hospital wards (1): nurses and clinical safety

Often, when we talk about clinical safety, we refer to specific activities such as hand washing or surgical checklist, but in this post I will try to explain the repercussions that the methods of working in hospital wards have on the quality of care. When people are admitted to a hospital, they put themselves in the hands of an army of professionals, who follow guidelines and are subject to shifts and medical guards. We must pay attention to all this, because the evidence has been warning us that what we call organizational factors weigh more than we think when it comes to hospitalized people’s health.

The 12-hour shifts are less secure for patients than the 8 hours shifts

A study conducted by the University of Maryland concludes that the probability of error is 3 times higher for nurses who work in 12-hour shifts compared to the one who work on 8 hours shifts. This finding has been corroborated by extensive research (22,000 records) conducted by the School of Nursing at the University of Pennsylvania.

The hidden curriculum: a matter of clinical safety

The medical hierarchy is a problem in medical education, and puts patients at risk. http://t.co/3fi2GmBWb5
— Lown Institute (@lowninstitute) February 12, 2014

Lown Institute, one of the organizations leading the movement "Right Care", is the author of this tweet that leads us to an article in the Health Affairs Journal, signed by Joshua M. Liao, a resident physician at Brigham and Boston Women's Hospital. Dr. Liao’s article speaks of the hidden curriculum concept described more than a decade ago by Frederic Hafferty, encompassing those masked values ​​conveyed through vocabulary, practices and habits, which end up having a powerful influence on the development of the trainees and, as such, even more than the diplomas contained in the formal curriculum.