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Category: medical errors (page 1 of 2)

Reducing Harm in Health Care

Gary Cohen, Co-Founder and President Health Care Without Harm, photographed in Charlestown, Mass., Friday, Sept 18, 2015, at The Spaulding Rehabilitation Hospital, one of the first hospitals built embracing Cohen's advocacy of self-sustaining, environmentally responsible healthcare networks. (Credit: John D. & Catherine T. MacArthur Foundation)

credit: MacArthur Foundation

When we talk about harm in the world of health care, we’re usually referring to patients and the facilities in which we provide care. These are the ‘typical’ things we hope to avoid, not only because they are bad outcomes, but because they now carry the specter of financial penalties when they occur:

  • medication errors
  • wrong side surgeries
  • hospital mishaps, like falls
  • missing a diagnosis
  • hospital-acquired infections and those induced by medical hardware

But Gary Cohen of the advocacy coalition Health Care Without Harm takes a much broader view of the harms that health enterprises can cause. Founded in 1996, HCWH is now a multi-national coalition of health care enterprises, governmental and non-governmental agencies, and other advocacy groups.

Cohen and HCWH have had some amazing successes. In less than two decades, HCWH has been able to reduce the number of medical waste incinerators in the U.S from more than 5000 to fewer than 100. Why should we care? It turns out that burning medical waste pours tons of the harmful chemical dioxin into the environment.

Another example: The formerly ubiquitous mercury thermometer. They used to break all the time. Fun to play with the drops of mercury, but highly toxic. Neurotoxic, in fact. And when mercury gets in our water supply, the fatty fish we eat (salmon, swordfish, tuna, mackerel, even shark) slowly poison us — which is why pregnant women and children are advised to avoid eating fresh fish in more than minute quantities.

HCWH was able to make the case that there are technological alternatives to mercury thermometers — that work just as well and are much, much safer. And they’ve been successful. When’s the last time you saw or used a mercury thermometer?

For this tireless advocacy, which also includes making hospital food supplies safer and hospital buildings themselves green and super safe (think natural disasters), Cohen was awarded a MacArthur Foundation Fellowship (think ‘genius grant’) last Fall.

You can hear an interview with Cohen here — give a listen and broaden your perspective on reducing harm in health care.

Vital Statistics Redux

top-10-causes-of-deathI’ve always had nagging doubts about filling out death certificates.

An excellent article in the trade paper “American Medical News” by Carolyne Krupa explores the “inexactitude” of the custom.

As Krupa points out, doctors are never taught how to fill out the documents. She quotes Randy Hanzlick, MD, chief medical examiner for Fulton County, GA:

“Training is a big problem. There are very few medical schools that teach it,” he said. “For many physicians, the first time they see it is when they are doing their internship or residency and one of their patients dies. The nurse hands them a death certificate and says, ‘Fill this out.’ ”

That’s pretty much how it works. Though sometimes the person that comes calling with the death certificate is a hospital clerk. And she will make you fill out the form carefully, using only ‘allowable’ causes of death.

Cause of death on this 1937 death certificate?  "Senile gangrene."

Cause of death on this 1937 death certificate?
“Senile gangrene.”

Of course, everyone dies from the same thing: lack of oxygen to the brain. But you can’t list that. Nor can you list common “jargon-y” favorites like “cardiopulmonary arrest,” “respiratory failure,” “sepsis,” or “multi-system organ failure.” All of which are true, but too inexact to be useful.

It’s intimidating to be the one to “pronounce” someone dead, and be the final arbiter of the cause. Isn’t that why we have medical examiners/pathologists?

We don’t autopsy patients much anymore, a trend that concerns many in the industry but doesn’t seem likely to change. That leaves interns and residents (at teaching hospitals) and community docs (in the real world) in charge of filling out these important statistical and historic documents.

When you care for a patient that dies in the hospital, your guess as to the cause can be pretty close. But without allowing for processes and instead requiring specifics (“pneumonia” instead of “respiratory failure”) it’s no wonder that when I was a resident, it seemed as though every patient died of a heart attack (“myocardial infarction”). This was one of the ‘allowable’ causes that seemed to apply whether it made the most sense or not.

If someone is really old and their body starts giving out, we can nearly always choose to say it’s because of their heart giving out. But what they most likely die from is “brain failure”–but there’s no category or term for that. The brain is the conductor of the body’s orchestra; but aside from ‘stroke’ (“cerebrovascular accident or disease”) we usually don’t list the brain in any of the causes (though stroke itself is #3 after heart disease and cancer).

Imagine getting a call from the police that a patient has died at home-a patient that you may not even know (when covering for a colleague, for example). How could I possibly know what the cause of death is?

Turns out our best guesses have to suffice. I’d favor a system that produces more reliable data.

This post originally appeared in January 2013. I repeated it because of the theme of uncertainty. Can you guess why?

From the Mailbag

Yes, we’re baaaa-aack. Here’s a letter from one of our readers:

Dear GlassHospital,

media hysteriaWhile I am a firm believer in the infallibility of doctors and modern medicine, I am desperately struggling with the Dallas handling of an Ebola patient. Sure, sometimes there’s that perfect storm of things gone wrong, opportunities missed, etc (think about the assassination story of Archduke Franz Ferdinand – seems it was destined to happen) but the spread of infectious diseases need not be history-making-world-changing-events in today’s “modern” era, should it? Is there that much of a divide between the knowledgeable and the uninformed – a gap that rivals our economic disparity? Is politics playing a role here, like [Texas Gov. Rick] Perry won’t allow any federal coordinated oversight/CDC management?

I used to watch silly action movies (“Whitehouse Down” for example) and think, “that would never happen! there’d never be such a dumb-ass breach of security like that!” Now I question if I’m the silly dumb-ass who believed there was a working system in place.

So tell me Dr. Glass: while I retain confidence in individuals and continue to hold doctors in high esteem, should I/can I trust hospitals?

Sincerely,

A Lost Patient

Pills. Lotsa, lotsa pills.

Ever get confused over the names of medicines?

I do. There’s Zantac. And Xanax. Zanaflex; Zaleplon.

But Zanaflex is also known as tizanidine. Tizanidine functions very differently than Zantac and it’s other name, ranitidine, even though they sound alike.pill-man

Every drug has (at least) two names—one proprietary, and one generic. Proprietary names are created to sound catchy by the original manufacturer, almost always under a patent. The generic names are more like chemical names, in that drugs of the same class that are similarly purposed will have common suffixes, like the cholesterol controlling pills known as  ‘statins’, or the cardiac medications known as ‘beta-blockers’ (whose names end with ‘-olol’).

As Theresa Brown points out in her most recent “Bedside” column, this is a recipe for disaster.

One way to cope with this issue in the medical world is to insist on the use of generic names. One of my professors used to do that. If a medication’s trade name was used, he would insist he’d never heard of that drug.

Medical journals, though chock-full of proprietary-named drug ads, insist on generic names in their scientific articles. Better to separate the wheat from the chaff.

One addition to Brown’s piece: There’s lots of confusion over generics, too. Since any drug manufacturer is able to make and sell generics, multiple companies can make the ‘same’ medication though the pills (because of the ‘inert’ additives) might look entirely different.

I riffed about this previously, and the harm it caused a patient of mine.

Why not mandate a standard pill size/shape/color for generics and minimize the likelihood of error?

Vital Statistic

top-10-causes-of-death

Click to enlarge.

I’ve always had nagging doubts about filling out death certificates.

An excellent article in the trade paper “American Medical News” by Carolyne Krupa explores the “inexactitude” of the custom.

As Krupa points out, doctors are never taught how to fill out the documents. She quotes Randy Hanzlick, MD, chief medical examiner for Fulton County, GA:

“Training is a big problem. There are very few medical schools that teach it,” he said. “For many physicians, the first time they see it is when they are doing their internship or residency and one of their patients dies. The nurse hands them a death certificate and says, ‘Fill this out.’ ”

That’s pretty much how it works. Though sometimes the person that comes calling with the death certificate is a hospital clerk. And she will make you fill out the form carefully, using only ‘allowable’ causes of death.

Cause of death on this 1937 death certificate?  "Senile gangrene."

Cause of death on this 1937 death certificate?
“Senile gangrene.”

Of course, everyone dies from the same thing: lack of oxygen to the brain. But you can’t list that. Nor can you list common “jargon-y” favorites like “cardiopulmonary arrest,” “respiratory failure,” “sepsis,” or “multi-system organ failure.” All of which are true, but too inexact to be useful.

It’s intimidating to be the one to “pronounce” someone dead, and be the final arbiter of the cause. Isn’t that why we have medical examiners/pathologists?

We don’t autopsy patients much anymore, a trend that concerns many in the industry but doesn’t seem likely to change. That leaves interns and residents (at teaching hospitals) and community docs (in the real world) in charge of filling out these important statistical and historic documents.

When you care for a patient that dies in the hospital, your guess as to the cause can be pretty close. But without allowing for processes and instead requiring specifics (“pneumonia” instead of “respiratory failure”) it’s no wonder that when I was a resident, it seemed as though every patient died of a heart attack (“myocardial infarction”). This was one of the ‘allowable’ causes that seemed to apply whether it made the most sense or not.

If someone is really old and their body starts giving out, we can nearly always choose to say it’s because of their heart giving out. But what they most likely die from is “brain failure”–but there’s no category or term for that. The brain is the conductor of the body’s orchestra; but aside from ‘stroke’ (“cerebrovascular accident or disease”) we usually don’t list the brain in any of the causes (though stroke itself is #3 after heart disease and cancer).

Imagine getting a call from the police that a patient has died at home-a patient that you may not even know (when covering for a colleague, for example). How could I possibly know what the cause of death is?

Turns out our best guesses have to suffice. I’d favor a system that produces more reliable data.

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