Just a pair of tweets that if we look at them with an appropriately skewed glance, we could see a lot of hope for cost control while providing better quality in healthcare.
11 deaths at Pasadena hospital may be linked to dirty scopes #superbug #ptsafety @melodypetersen https://t.co/e0qZ1VOo1k
— Chad Terhune (@chadterhune) June 1, 2016
Attitudes in two different industries pic.twitter.com/fwcVLmuLGK
— James (@jameswhatling) May 17, 2016
We all fuck up.
Well designed systems of learning and error minimization acknowledge that we fuck up and create a culture and systems to minimizing common fuck-ups. Aviation has that culture while medicine may have it in isolated pockets but it is not widespread.
Vanity Fair had a good article on the loss of Air France 447 over the Atlantic in 2009 and it raised a couple of interesting points:
It all depended on the captains. A few were natural team leaders—and their crews acquitted themselves well. Most, however, were Clipper Skippers, whose crews fell into disarray under pressure and made dangerous mistakes. Ruffell Smith published the results in January 1979, in a seminal paper, “NASA Technical Memorandum 78482.” The gist of it was that teamwork matters far more than individual piloting skill. This ran counter to long tradition in aviation but corresponded closely with the findings of another NASA group, which made a careful study of recent accidents and concluded that in almost all cases poor communication in the cockpit was to blame.
The airlines proved receptive to the research. In 1979, NASA held a workshop on the subject in San Francisco, attended by the heads of training departments from around the world. To describe the new approach, Lauber coined a term that caught on. He called it Cockpit Resource Management, or C.R.M., an abbreviation since widened to stand for Crew Resource Management. The idea was to nurture a less authoritarian cockpit culture—one that included a command hierarchy but encouraged a collaborative approach to flying, in which co-pilots (now “first officers”) routinely handled the airplanes and were expected to express their opinions and question their captains if they saw mistakes being made. For their part, the captains were expected to admit to fallibility, seek advice, delegate roles, and fully communicate their plans and thoughts. Part of the package was a new approach to the use of simulators, with less effort spent in honing piloting skills and more emphasis placed on teamwork.
How does this apply to the medical field and how do we get some hope.
The scope example is a common and preventable fuck-up with significant probable harm. If those are the types of errors that we are still failing miserably to avoid, that means that the medical system current state is amazingly far from the possibility frontier of perfect execution or at least air line level execution. Minor gains can be made fairly easily with significant improvements as most of the time quality improvement is a Pareto exercise. 80% of the gains can be achieved by 20% of the work needed to get to the possibility frontier.
The chart about team work and quality improvement for airline pilots shows a culture that acknowledges their humanity. The medical side of the chart is a culture of the heroic authoritarian hero. Culture change is often harder to do then technological change but it tends to be cheaper over the long run. There is an opportunity here for improvement so that has to be a source of hope.
Ruckus
Another problem is there are now more antibiotic resistant bugs. So even doing everything doesn’t always work.
LAO
This scope thing terrifies me. As a person with a GI disease, bacterial laden scopes are my worst medical nightmare.
Dan
In aviation, your life is also at stake. Not so in medicine.
oldster
wow–that contrastive survey of attitudes among pilots and MDs is such a terrific eye-opener.
I’d love to see that more broadly applied to more industries.
Amir Khalid
@Dan:
???
aimai
@Dan: I suppose we could fix that by executing doctors who lose patients? But its not true that “in aviation” you risk your own life. An enormous part of the safety equation is ground crews doing their jobs. They don’t die in crashes.
Jeffro
Shocked that they got 30% of doctors to admit they think they make mistakes…
Major Major Major Major
@Amir Khalid: He means that the practitioner’s life is at stake.
That doctor poll thing is gross, but not unexpected.
WarMunchkin
That second chart/tweet appears to be about the UK system. Do we expect to see different attitudes by employees in our system?
piratedan
cultures and risk are different animals…. docs are taught that they are the end all be all, as such, information from the lowly nurse or worse yet, clinical lab staff runs counter-intuitive to what’s been beat into their heads for roughly a decade before they go out on their own and as someone has noted upstairs, if they screw up, somebody else dies, but who’s going to review their work? Who is worthy of doing so?
As for infection control, a common anecdote is that you have docs infecting patients because they’re so busy, they never get their ties dry cleaned. IC is a big deal and many hospitals are doing their best to control those vectors and many states are gathering stats that track what bugs are out there and who is getting them.
eclare
I think a lot of this was also in response to the crash of two 747’s on taxiways in the Canary Islands in 1977. Junior crew did not question the KLM pilot who insisted on taking off in the fog. Great documentary about it (at least one) if you get the chance. Entire incident could have been avoided.
LAO
I think one factor for the difference, is that individual doctors have personal liability for medical errors, whereas I can’t recall a pilot or grounds crew being held financially responsible for an error. That liability lies with the airline that employs them.
@Jeffro: I’m assuming it was the nurses who admitted to making mistakes, since the survey does not breakdown the medical personnel.
Amir Khalid
@eclare:
As I seem to recall, that KLM pilot was the most senior at the airline, so he wasn’t someone you dared question unless you were very sure of yourself.
The Moar You Know
Yay, I’m getting scoped tomorrow. I think I need to go take a bottle of Ativan now.
But before, yeah, CRM works. My dad was a co-pilot when it was instituted, and he was damn glad. Some not very good captains flying at the time. Oddly enough, they tended to be the guys who hated CRM most and a not insubstantial number of them left over it. Win-fucking-win.
It still has problems, largely cultural issues, and you see it most in native Asian flight crews, where contradicting an older person with superior rank is simply not done in the culture. Asiana 214 at SFO was the most recent manifestation of the phenomena. The captain had clearly fucked up and nobody wanted to tell him he had. FIVE guys on the flight deck (crowded!) and nobody said anything until they were fifty feet from the breakwater, and by then it was WAY too late.
Anyhow, now back to shitting my pants over tomorrow’s endoscopy.
Joel
@Ruckus: Improved practices (sanitation, e.g.) would slow down the growth rate of antibiotic resistance.
Hillary Rettig
Just. wow. The delusions of the medical staffers is scary. What reasonable person believes they don’t make mistakes?
I read a while back that a lot of hospital errors derive from poor communications among the medical personnel (for instance, as a result of shift changes). So I pay attention to that when I or someone else needs treatment.
And the silo’ing…I have a young relative who had several autoimmune things going at once. She saw top doctors in the NY metro area for years, with only (very) partial success. It wasn’t until she went to the Philly Children’s Hospital, where the entero, immuno, endochronologist, and other specialists all got in a room together and actually talked that she was properly diagnosed and treated.
Mike J
Pilots are on the plane. If it crashes, they die. Doctors are not “on the plane”. If it crashes, they go home.
Joel
Is that NHS lecture from 16 years ago or are they presenting old data?
Villago Delenda Est
We all fuck up, but some of us have an intense desire to deny that we fucked up, for legal reasons.
Seanly
I design highway bridges for a living. The culture within structural engineering is to check and verify assumptions and calculations. We can make bad assumptions and carry out perfect calculations on that. We can make great assumptions and then transpose a couple of numbers or forget to convert inches to feet in the structural analysis. Software is a great tool but garbage in equals garbage out (and no software is bug free).
I personally am willing not just to speak up if I see an issue but also to listen when someone else has something to say. Young engineers can ask great questions and senior engineers can get a little complacent.
Of course, like any industry, there are people who can’t handle being told they made an error…
Wag
@Joel:
Stopping the industrial use of antibiotics in factory farms would do the most good
The Moar You Know
@Mike J: You’d be floored to see how little that matters to a certain type of captain who has just had his authoritah questioned. You really would. They’d far rather be unquestioned and dead than have to answer to some underling.
gene108
@Hillary Rettig:
Had some tests run at Penn Hospital.
The doctor, who was performing the test asked me which doctor referred me. I forgot, which doctor initially referred during my initial evaluation.
Luckily there was a name on the prescription given for the test. I had to tell them what other doctors (GP, nephrologist, etc.) I needed the tests to go to.
I am completely convinced you have to track every little detail of what a hospital is doing to you, who is doing it you and what they are doing, because they seem barely able to keep track.
Napoleon
@aimai:
This is the first thing I thought of when I saw this post. I didn’t read the book but did listen to several interviews with him and some short articles written by him around the same time and was gob smacked by the medical fields not use of/resistance to use checklist, and I don’t recall how explicit he was but it seemed like the “heroic authoritarian hero” culture was a real issue with the medical field. Their failure to do so is as negligent as if they will still cleaning medical instruments in urine or bleeding patients.
Gian
Just getting medical staff trained to wash hands correctly and often enough is hard.
And the sleep deprivation hell that they put interns through is, especially for people who are supposed to be in a scientifically grounded profession of helping people, insane.
RSR
Yet CNN spends months looking for the plane rather than the dirty scopes.
a hip hop artist from Idaho (fka Bella Q)
I think it was the Atlantic that published the report about Air France 447, and noted that the gist of the report was the the crew flew a perfectly good aircraft into the ocean based on a cascade of errors across several different people, that in the end the captain couldn’t fix.
Atul Gawande’s book, The Checklist explains the issues around medical errors and how to avoid (ideally) them. It’s well worth a read.
Capri
FWIW, I think the medical profession is coming around. One of the first things my son had to do when in medical school is explain to a pretend patient’s family that a medical error occurred in his “How to communicate with humans” class.
amygdala
If anyone is interested, here is the actual paper from which the pilots versus medical staff data are derived.
Roger Moore
@Joel:
The big problem with the duodenoscopes, though, is that they’re nearly impossible to clean, so the sanitation issue isn’t that simple. The LA Times has been really digging into the issue, and they’ve had a whole long series of articles. It really points to a cultural problem that extends far beyond the practitioners and into the manufacturers.
The newest generation of scopes are a real marvel that allow less invasive surgery, but packing all that stuff into a device that can fit down somebody’s throat has unfortunately made them very difficult to clean. The manufacturers- principally Olympus, but it sounds as if the other manufacturers aren’t a lot better- have blamed problems on inadequate cleaning of the scopes. That, and the worry about bad PR, encourages the hospitals to keep quiet about their problems rather than discussing them openly- which makes it that much easier for the manufacturers to mislead other hospitals into accepting that the problems are entirely their fault for failing to clean the scopes correctly. Meanwhile, it turns out that even following the manufacturer’s recommendations doesn’t get the scopes clean every time, so there’s definitely a design problem.
Now it sounds as if the outbreak at Huntington is actually in a different category. They were using an older-generation scope that isn’t supposed to have the same problems with cleaning, and it sounds as if they weren’t following the correct cleaning protocol. OTOH, the issue with lack of mandatory reporting is still there, so the hospital tried to keep things quiet- unsuccessfully, because the local paper has really gone on a tear about the issues with the newer scopes.
Blueskies
@gene108: Now ponder what it’s like if you’re over 80 and starting to have cognitive issues and your SO is deceased and your kids live out of state. There’s no communication among anyone and there’s no follow-up. You know why? Because docs aren’t paid to talk to other docs. It doesn’t even occur to them.
I was just discussing this with a colleague. To our knowledge, this isn’t a problem in Canada, UK, or France. Almost everything is team-oriented in the those countries. Gee, what’s the common denominator?…
Roger Moore
@gene108:
That depends on the hospital. I have been very impressed with Kaiser when it comes to medial records. Everything goes into a single EMR system, and the doctors have immediate access to it. As far as I can tell, the only paper you ever see is the summary they print out for you at the end of your visit.
Eric U.
the surgeon that endoscoped my colon followed that by endoscoping someone from the other end (there is a limit to how much hippa can conceal). I joked with the nurse that I hope they cleaned the instrument really well. So now I know it was a valid concern.
Ruckus
@Joel:
Even best practices don’t catch everything. I have experience in this area. Two trips to the ER and massive antibiotics fixed me but that was three weeks I’ll never get back.
Ruckus
@Roger Moore:
Electronic records can help dramatically, if they are used properly. The VA does pretty good and one reason is electronic records.
Gindy51
Pilots are also randomly drug tested and have to retrain at least once every year. My daughter had every one of her grand parents either killed or fatally harmed by the medical profession, so I have NO faith in any of them and question every doctor, nurse, LPN, and pharmacist. I do tons of research before I even think of calling a doctor and watch them like a hawk.
When my husband had his knee operated on, the nurse came into his recovery room to remove his bandages without washing her hands. I blocked her access and made her wash them. That is how carefully you have to watch them.
StringOnAStick
The most out of control professional I’ve ever met was a libertoonian MD, and I’ve noted that medicine and dentistry have more than their fair share of these authoritarian jerks. I tend to see it less in much younger docs because they went into med school knowingly US medicine was changing; its the older ones who are bitter about the changes they’ve seen in their careers.
I work in dentistry as a second career and my first job was with a husband &wife team that eventually got nailed for insurance fraud (I was long gone by then). She would lecture us at lunch about how we’d better not vote for Obama. After I quit there I temped for 6 years just to avoid ever being in that position again. One office I temped at played Fox news all day in the waiting room but most offices keep politics out of it even though most DDS’s are conservative. I found a mensch of a liberal to work for; if you like your dds and you suspect they are liberal, find out and tell your friends to go there. My temping experience showed me that the more conservative, the more of a wallet-miner. If you feel like you are being sold on something, you probably are!
amygdala
@Ruckus: The VA and Kaiser have systems that enhance care, and the data to back that up. EHR has been disaster just about everywhere else. They’re billing (not patient care) systems, often non-interoperable, running on unreliable hardware. Even better, the keyboards are full of horrible bacteria. It’s a multidimensional cluster*ck.
TPTB in my former hospital were foolish enough to send around a survey about one of the dozen or more EHRs that were simultaneously running some years ago. I knew full well it wasn’t really anonymous, but was past caring about an adminobot calling me into his or her office about not being a team player. So I typed out a list of bullet points of the problems, and concluded that “IT should be commended for developing a system that makes care both more unsafe and less efficient.” They were completely uninterested in end-user input during the design phase.
When the ACA passed, I saw the EHR section and had a bad feeling it would be a mess. In a better world, the VA’s CPRS would have been made a national standard (it’s open source and designed to work, as I understand it, across a broad array of hardware, since some VA clinics don’t have shiny, fancy computers). It just would have taken someone writing a billing module for it. There would have been a lot of efficiencies–interoperability across facilities, the ability to train medical/nursing/pharmacy/PT/OT/SW students in school on it, among others.
But that would have violated whatever shadow Constitutional Amendment it is that enshrines the right of fly-by-night software companies to make work days abject hell for health care workers.
Geeno
I was recently getting scoped at the local hospital – all the hospitals here are part of the University of Rochester – and they not did a checklist – it was on the wall of my bed area, and they signed things off as they did them.
Wash hands and change gloves was on it like three times for the nurse who was prepping me.
Roger Moore
@Ruckus:
I assume that a big thing that makes electronic medical records work is when you can be sure that everyone is using them consistently. That’s really hard in a typical provider network because they aren’t built as systems; they’re just a bunch of providers who all take money from the same insurance company. In many cases, each provider is part of multiple networks, so it’s going to be really hard to enforce standardization until there’s one system that’s used across all providers in the country. It’s much easier to manage in an actual system like the VA or Kaiser. They’re both integrated payer/provider networks, so the payer actually owns and can enforce standardization on the providers.
amygdala
@Roger Moore: Yup. Also, Kaiser and the VA make sure the various moving parts are well-integrated. It had gotten to the point, when I retired, that I had to have 3 different systems open in clinic, in order to have access to inpatient notes, radiology results, and the outpatient note I was trying to write. On a wi-fi network so slow I could swear I was hearing the static of a phone modem.
And I would still have to walk around the corner to the eye clinic when I needed to review their notes, because those were on a different system that was unavailable to everyone else.
It’s probably not an exaggeration to say that stuff like this contributes to driving clinicians out of patient care. Exactly what we don’t need with a decades-long global nursing shortage and looming US physician shortage.
Geeno
@Geeno: That should be “not ONLY did a checklist” ….
Geeno
@Roger Moore: I’ll bet a lot of what works around here does so, because even if YOU aren’t a UofR provider, you HAVE to be able to interact with them, or you won’t get referrals.
The local Goliath has enforced a significant amount of standardization.
greennotGreen
The medical center where I worked for 29 years and where I am a patient of the cancer center has had electronic medical records for years. I have not been on the staff side of those records, but I certainly appreciate being able to check my appointments and test results online.
Before chemo is administered, one nurse pulls up the orders, reads them out, reads out my name, DOB, and patient ID from my hospital wrist band while another nurse checks that all the information is correct. They also check with me. At another hospital where that was not done due to understaffing, I was almost given the wrong meds.
My take on EHR – excellent if the software is good, the training is good, and the execution is good. And sufficient staffing helps.
Feathers
@amygdala: Yes. This. Any sane world would require all EHS software to be open source, if only to allow for interoperability tweaks and customizing for legacy systems.
john fremont
@Gindy51: Also too, in aviation, mechanics and avionics technicians, especially those that work for air carriers and repair stations, are trained every year on safety and maintenance practices. One training semiar is in the “Dirty Dozen.” It includes checklists for tool inventory, reviewing procedures and asserting oneself when feeling pressure to complete a job may jeopardize safety of flight. One interesting thing was keeping overconfidence in check. Aviation maintenance stresses a lot of working with the latest revision of the technical manual. I don’t care how many times you have done it, aircraft mechanics and technicIans are not impressed by a guy that claims to do things from memory. They better have the latest maintenance manual before they put a wrench to that aircraft.
Texasdoc
@Blueskies: Someone above talked about silo’ing–and that is true with information in medical records. We’re all using electronic medical records now, but the only sharing of information is between people in the same system. I’ll see someone for cancer, but his GI doc’s notes and test results are sent to me as paper records, because the two EMR’s don’t share info or communicate at all. I’ve always thought that sharing of info with other doctors seeing a patient should have been the prime requirement for approval of EMR programs from the very beginning. Now we’ll spend billions of dollars to retrofit existing systems to allow information exchange.
Ruckus
@amygdala:
Sounds about right.
The VA computers are about as far from leading edge as you can get. Basic winders machines. Not fast but they work. The biggest thing though is that you are right about the entire system is designed to make the job easier. But the system they work in is what does most of the heavy lifting. The staff are all employees of the government, not individual docs or offices, or independents. You want to work there, you follow the rules. And the rules are built around providing good care, not feeding the docs egos or their wallets. I never talked longer than 10 minutes (and most not longer than 5 minutes) to any private doc in my life other than one ortho surgeon. I routinely talk 20-30 minutes if needed. I never feel rushed to get out. I almost always felt that with private docs. I have very little exposure to Kaiser but that made me think they used the VA as a role model to set up the HMO. The money end does come into it a bit but certainly not as much as most other suppliers.
Ruckus
@Roger Moore:
@amygdala:
Oh exactly. I can even look up my file and doc notes, all my meds, appointments, I can refill meds, all without having to interact with anyone and waste their time. Bet you can’t do that with Kaiser. I can go to any VA facility and they can check my records as well. I go to 2 different clinics and 1 hospital now and there is no problem with any of that. Everyone who sees me knows my meds and the system won’t let them prescribe conflicting meds in any event. There are sections for them to check all my issues to see if something new belongs to a prior diagnosis.
It’s actually all pretty cool if you look at the system that most of you use. Yes one does have to wait your turn, sometime much longer than in the non VA world, but never if waiting is an immediate health issue.
TriassicSands
@The Moar You Know:
No, no, no. You’ve got it all wrong. You shit your pants over a colonoscopy; you throw up if it’s an endoscopy.
I’m not sure why you are so concerned. Endoscopies are painless* and don’t take long generally. And preparing for one is certainly more pleasant than prepping for a colonoscopy. (I had my last colonoscopy 8 days ago. Since 2010 I’ve had four colonoscopies and two upper endoscopies — no negative after effects from any them.)
Good luck with your procedure. I expect you’ll be fine.
* I’ve never had any negative after effects of an upper endoscopy. I guess it is possible to have an irritated throat, but I don’t think that is a serious concern.