With the goal of making health care safer, the Obama administration is drafting a novel system for patients to report medical errors. No system of this scale currently exists. The primary questions in the draft are, "Have you recently experienced a medical mistake? Do you have concerns about the safety of your health care?" Respondents are also asked to indicate potential reasons for the error such as "A health care provider was too busy" or "Health care providers failed to work together." They even have the option to report specific names of providers (physicians, nurses, etc) and their addresses.
After reading this article, a few questions came to mind and I'd be interested in hearing other people's thoughts.
1. Are consumers the best source of information for medical errors?
While I absolutely agree that patients' perceptions are a key components of their health care experience and they often have helpful insights to improve their care, I do not think that they are the best judge of what went wrong. And focusing on vague reasons such as excessive provider workload and cultural competency do not get to the heart of the problems nor do they offer specific solutions. Further, it is unlikely that patients can provide enough detail of their care to allow adequate evaluation of the holes in a health care system. However, this information may be useful to identify broad trends in patient care over time.
2. How should this information be used? Will it be made public?
In other industries where workplace safety is a significant concern, the threat of punitive action impedes error reporting. The ultimate goal is to minimize preventable adverse health effects from medical errors not just reduce the apparent number of errors. Also, I think patients who experience medical errors but have them acknowledged and explained by the provider would actually be reluctant to use this reporting system if it could get their provider "in trouble."
3. Are there better alternatives?
I think so. Focusing on quality measures, requirements for all health care organizations to have a process for medical error reporting and evaluation, and making specific health outcomes (eg. surgery mortality rates) transparent are more effective solutions, in my opinion.
4 comments:
I saw the headline, and my initial instinct was "uh-oh." I don't like the idea of depending on Yelp-style reviews to influence the amount or way a provider is paid. After reading the article, I have mixed feelings. The article doesn't lay out a convincing explanation of where the data will go, or what the follow-up will be. Investigation of claims could be costly and onerous. I would be interested to know how the ECRI Institute currently investigates medical errors, and how that might change if the volume of reports increases substantially, as might be the case with this new system.
I do see some potentially beneficial uses for the information, however.
I think the best use of this system could be to highlight trends in medical mistakes, rather than to investigate specific errors. This could give administrators bottom-up information they could then use to design and implement structural improvements to reduce such errors. The way the phone surveys are designed, by giving folks options for what may have caused the error, seems geared towards this end. For example, if a high percentage of complaints were related to the fact that "health care providers were not aware of care received someplace else," governmental or organizational pressure to improve outcomes could result in increased efforts to communicate and share records across different clinics, offices, hospitals, and EHRs.
Side note: The article mentioned that patient perception can skew the data, giving the example of a patient complaining of an infection due to a reddened surgical site. The article suggested that the solution would be comparing data to medical records to more accurately grasp the situation, yet I imagine that would be difficult, due to HIPAA and the necessary effort and participation required of the site of the patient's care. In looking at complaints of this type, I would argue that the quality improvement that could be made is patient education, rather than better medical outcome.
I think this is a very interesting article here are my thoughts on this -
1. I think this article suggests an implied minimization or underreporting of medical errors by physicians and hospitals. In fact in my experience I have seen the response to medical errors being quite contrary to popular belief. Morbidity and Mortality sessions held at academic and community medical institutions present some evidence against this notion. Medical errors leading to any adverse outcomes are very seriously investigated and steps are taken to prevent similar errors from happening in the future. In places where such M&M sessions are not the norm, a concerted effort should be made to make these sessions mandatory.
2. Like every other profession medicine is practiced by humans, and humans make errors. Unlike the car industry where there is an opportunity to do crash testing and ensure safety prior to launch, such preventative strategies might not exist in medicine and often unfortunately we have to rely on learning from adverse outcomes which is what currently occurs in most healthcare institutions.
3. Efforts made to prevent medical errors from occurring often involve use of defensive medicine by providers. The strongest evidence for this exists in the well-known overuse of imaging services. While this is possibly lowering the rate of medical errors, it’s leading to an increase in radiation exposure and numerous other unneeded procedures such as biopsies. Each of these procedures carries further risks.
4. There are certain medical errors which should never be tolerated; however the current focus on punishment for medical errors is wrong in my opinion. I think medical error reporting should be encouraged and the motive behind this should be to recognize deficits in medical care and improving on these deficits. Large academic institutions currently treat information on medical errors as proprietary and don’t release these results to the public due to fears of litigation. Perhaps more good could be achieved by encouraging release of this information by focusing on improvement in medical care using this data and accepting the fact that medical errors while horrible are often made by ordinary humans trying to do the best they can.
Looking at the possible reasons the questionnaire gives for the medical mistake, such as, “A health care provider didn’t seem to care about the patient,” this seems more an assessment of bedside manner and doctor-patient interface than anything else. I won’t say that it’s useless to collect this information because it’s true that a poor doctor-patient relationship can lead to medical errors. For example, errors can occur the doctor is too rushed to address the patient’s needs or doesn’t explain instructions in ways the patient can understand and follow. However, given the patient’s limited perspective of what may have contributed to the error, and lack of medical knowledge, this assessment seems too superficial to gain any real actionable data on this issue.
Also problematic is that it’s unclear from this article what the goal of this undertaking is and what exactly the government will use the information for. I imagine that the administrative costs associated with collecting and compiling this information will be high, and if there are no substantive outcomes in terms of exposing or fixing errors, I question whether this is an effective use of government resources. It could potentially even lead to greater patient frustration if they expect to see follow-up or results that don’t occur. It would be better to have these sorts of assessments conducted at a local level or by hospitals/doctors offices themselves, where they can investigate and better remedy the problems.
I'm of two minds on this one. I am a huge fan of soliciting feedback from patients, and I agree that they often know or see things that their care providers may not be aware of. I see three categories of feedback: feedback on the quality of what I'll call "bedside manner" ( eg lapses in cultural awareness, taking the time to explain what's happening, etc); medical mistakes (eg failing to record drug prescriptions in a patient's chart); and false negatives (a patient misinterpreting regular healing as an adverse event). The third is not helpful and I think that people who are concerned about patient feedback focus on this category. However, the first two categories could provide valuable information to the institution that could help them improve processes and services for future patients.
Having said all that, I am far from convinced that the federal government is the best organization to be collecting this data. From my best recollection, AHRQ is terribly underfunded, and I am concerned that the data would end up either not being used at all or being used in the simplest way (hospital rankings) rather than in a productive drive to reduce mistakes. Only the provider organization is really in a position to make positive change, so it is really ideal for them to be the ones who gather the data directly.
Amar, you brought up M&M sessions, as one of the most well-established ways that hospitals do quality control. Do you know to what extent provider organizations have a way to record and analyze mistakes that do NOT result in adverse events? It seems to me that there are a lot of mistakes that cause no serious harm and these would be an easier ground to look into what happened, because you don't have to worry as much about the individual provider feeling bad about any role they may have played in hurting someone. I have no doubt that if the process could be improved for these more benign cases, then that would help to prevent the mistakes that lead to more serious adverse events. Is this done differently by different institutions?
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