Health

Patient safety

Published by Anonymous (not verified) on Fri, 21/09/2018 - 11:36pm in

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Health


An issue which is of concern to anyone who receives treatment in a hospital is the topic of patient safety. How likely is it that there will be a serious mistake in treatment -- wrong-site surgery, incorrect medication or radiation dose, exposure to a hospital-acquired infection? The current evidence is alarming. (Martin Makary et al estimate that over 250,000 deaths per year result from medical mistakes -- making medical error now the third leading cause of mortality in the United States (link).) And when these events occur, where should we look for assigning responsibility -- at the individual providers, at the systems that have been implemented for patient care, at the regulatory agencies responsible for overseeing patient safety?

Medical accidents commonly demonstrate a complex interaction of factors, from the individual provider to the technologies in use to failures of regulation and oversight. We can look at a hospital as a place where caring professionals do their best to improve the health of their patients while scrupulously avoiding errors. Or we can look at it as an intricate system involving the recording and dissemination of information about patients; the administration of procedures to patients (surgery, medication, radiation therapy). In this sense a hospital is similar to a factory with multiple intersecting locations of activity. Finally, we can look at it as an organization -- a system of division of labor, cooperation, and supervision by large numbers of staff whose joint efforts lead to health and accidents alike. Obviously each of these perspectives is partially correct. Doctors, nurses, and technicians are carefully and extensively trained to diagnose and treat their patients. The technology of the hospital -- the digital patient record system, the devices that administer drugs, the surgical robots -- can be designed better or worse from a safety point of view. And the social organization of the hospital can be effective and safe, or it can be dysfunctional and unsafe. So all three aspects are relevant both to safe operations and the possibility of chronic lack of safety.

So how should we analyze the phenomenon of patient safety? What factors can be identified that distinguish high safety hospitals from low safety? What lessons can be learned from the study of accidents and mistakes that cumulatively lead to a hospitals patient safety record?

The view that primarily emphasizes expertise and training of individual practitioners is very common in the healthcare industry, and yet this approach is not particularly useful as a basis for improving the safety of healthcare systems. Skill and expertise are necessary conditions for effective medical treatment; but the other two zones of accident space are probably more important for reducing accidents -- the design of treatment systems and the organizational features that coordinate the activities of the various individuals within the system.

Dr. James Bagian is a strong advocate for the perspective of treating healthcare institutions as systems. Bagian considers both technical systems characteristics of processes and the organizational forms through which these processes are carried out and monitored. And he is very skilled at teasing out some of the ways in which features of both system and organization lead to avoidable accidents and failures. I recall his description of a safety walkthrough he had done in a major hospital. He said that during the tour he noticed a number of nurses' stations which were covered with yellow sticky notes. He observed that this is both a symptom and a cause of an accident-prone organization. It means that individual caregivers were obligated to remind themselves of tasks and exceptions that needed to be observed. Far better was to have a set of systems and protocols that made sticky notes unnecessary. Here is the abstract from a short summary article by Bagian on the current state of patient safety:

Abstract The traditional approach to patient safety in health care has ranged from reticence to outward denial of serious flaws. This undermines the otherwise remarkable advances in technology and information that have characterized the specialty of medical practice. In addition, lessons learned in industries outside health care, such as in aviation, provide opportunities for improvements that successfully reduce mishaps and errors while maintaining a standard of excellence. This is precisely the call in medicine prompted by the 1999 Institute of Medicine report “To Err Is Human: Building a Safer Health System.” However, to effect these changes, key components of a successful safety system must include: (1) communication, (2) a shift from a posture of reliance on human infallibility (hence “shame and blame”) to checklists that recognize the contribution of the system and account for human limitations, and (3) a cultivation of non-punitive open and/or de-identified/anonymous reporting of safety concerns, including close calls, in addition to adverse events.

(Here is the Institute of Medicine study to which Bagian refers; link.)

Nancy Leveson is an aeronautical and software engineer who has spent most of her career devoted to designing safe systems. Her book Engineering a Safer World: Systems Thinking Applied to Safety is a recent presentation of her theories of systems safety. She applies these approaches to problems of patient safety with several co-authors in "A Systems Approach to Analyzing and Preventing Hospital Adverse Events" (link). Here is the abstract and summary of findings for that article:

Objective: This study aimed to demonstrate the use of a systems theory-based accident analysis technique in health care applications as a more powerful alternative to the chain-of-event accident models currently underpinning root cause analysis methods.
Method: A new accident analysis technique, CAST [Causal Analysis based on Systems Theory], is described and illustrated on a set of adverse cardiovascular surgery events at a large medical center. The lessons that can be learned from the analysis are compared with those that can be derived from the typical root cause analysis techniques used today.
Results: The analysis of the 30 cardiovascular surgery adverse events using CAST revealed the reasons behind unsafe individual behavior, which were related to the design of the system involved and not negligence or incompetence on the part of individuals. With the use of the system-theoretic analysis results, recommendations can be generated to change the context in which decisions are made and thus improve decision making and reduce the risk of an accident.
Conclusions: The use of a systems-theoretic accident analysis technique can assist in identifying causal factors at all levels of the system without simply assigning blame to either the frontline clinicians or technicians involved. Identification of these causal factors in accidents will help health care systems learn from mistakes and design system-level changes to prevent them in the future.
Key Words: patient safety, systems theory, cardiac surgical procedures, adverse event causal analysis (J Patient Saf 2016;00: 00–00)

Crucial in this article is this research group's effort to identify causes "at all levels of the system without simply assigning blame to either the frontline clinicians or technicians involved". The key result is this: "The analysis of the 30 cardiovascular surgery adverse events using CAST revealed the reasons behind unsafe individual behavior, which were related to the design of the system involved and not negligence or incompetence on the part of individuals."

Bagian, Leveson, and others make a crucial point: in order to substantially increase the performance of hospitals and the healthcare system more generally when it comes to patient safety, it will be necessary to extend the focus of safety analysis from individual incidents and agents to the systems and organizations through which these accidents were possible. In other words, attention to systems and organizations is crucial if we are to significantly reduce the frequency of medical and hospital mistakes.

(The Makary et al estimate of 250,000 deaths caused by medical error has been questioned on methodological grounds. See Aaron Carroll's thoughtful rebuttal (NYT 8/15/16; link).)

Blunt message to states from Canberra on recreational cannabis

Published by Anonymous (not verified) on Thu, 20/09/2018 - 8:29am in

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Health

The latest revenue projections for the US cannabis industry shows a revenue decrease for medicinal cannabis from $5.9 billion in 2017 to $4.3 billion in 2018.

Crisis? What crisis?

Published by Anonymous (not verified) on Wed, 19/09/2018 - 8:56am in

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Health

Crisis is a word all too often thrown around in relation to the aged care industry. Sadly the frequency with which that word is employed has been blunted.

How the aged care sector deals with commonwealth funds

Published by Anonymous (not verified) on Fri, 14/09/2018 - 9:19am in

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Health

When some 1717 claims were evaluated, close to 40% of those assessed by the Commonwealth were downgraded in one or several of the 12 segments of the claim.

Animal on the Street - Probiotics do nothing.

Published by Anonymous (not verified) on Mon, 10/09/2018 - 10:55pm in

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Health, News

The pandemic to end all pandemics: influenza in 1919

Published by Anonymous (not verified) on Fri, 07/09/2018 - 9:01am in

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Health

The 1919 influenza pandemic stands as the greatest social and health disaster in Australian history. Overall millions succumbed to flu during the first six months of 1919 and at least 15,000 died.

The Alcohol and Health Puzzle

Published by Anonymous (not verified) on Fri, 07/09/2018 - 3:16am in

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Health

Alcohol in any quantity may cause health problems, according to recent research. That settles a medical problem, but opens a behavioral one.

How to Avoid Prescription Drug Problems

Published by Anonymous (not verified) on Sun, 26/08/2018 - 6:03am in

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Health

You can avoid negative outcomes from prescription medications, including the worst outcome of all.

Cholesterol and Heart Disease: What's the Real Link?

Published by Anonymous (not verified) on Thu, 23/08/2018 - 2:38am in

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diet, Health

Is LDL cholesterol the cause of heart disease—or merely a marker of indiscretion?

Obesophobia

Published by Anonymous (not verified) on Fri, 17/08/2018 - 4:27pm in

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Food, Health

In 1976, we ate more than we do today. So why are we fatter?

By George Monbiot, published in the Guardian 15th August 2018

When I saw the photo, I could scarcely believe it was the same country. The picture of Brighton Beach in 1976 featured in the Guardian a few weeks ago appeared to show an alien race. Almost everyone was slim. I mentioned it on social media, then went on holiday.

When I returned, I found that people were still debating it. The heated discussion prompted me to read more. How have we changed so far, so fast? To my astonishment, almost every explanation proposed in the thread turned out to be untrue.

Unfortunately, there are no consistent obesity data in the United Kingdom before 1988, at which point the incidence was already rising sharply. But in the US, the figures go back further. They show that, by chance, the inflection point was more or less 1976. Suddenly, at around the time when the photograph was taken, people started becoming fatter, and the trend has continued ever since.

The obvious explanation, many of those debating the photo insisted, is that we’re eating more. Several pointed out, not without justice, that food was generally disgusting in the 1970s. It was also more expensive. There were fewer fast food outlets and the shops shut earlier, ensuring that if you missed your tea, you went hungry. So here’s the first big surprise: we ate more in 1976.

According to government figures, we currently consume an average of 2131 kcals per day, a figure that appears to include sweets and alcohol. But in 1976, we consumed 2280 kcal, excluding alcohol and sweets, or 2590 when they’re included. Can this really be true? I have found no reason to discredit the figures.

Others insisted that the cause is a decline in manual labour. Again, this seems to make sense, but again the data don’t support it. A paper in the International Journal of Surgery states that “adults working in unskilled manual professions are over 4 times more likely to be classified as morbidly obese compared with those in professional employment”.

So how about voluntary exercise? Plenty of people argued that, as we drive rather than walk or cycle, are stuck to our screens and order our groceries online, we exercise far less than we did. It seems to make sense – so here comes the next surprise. According to a long-term study at Plymouth University, children’s physical activity is the same as it was 50 years ago. A paper in the International Journal of Epidemiology finds that, corrected for body size, there is no difference between the amount of calories burnt by people in rich countries and in poor ones, where subsistence agriculture remains the norm. It proposes that there is no relationship between physical activity and weight gain. Many other studies suggest that exercise, while crucial to other aspects of good health, is far less important than diet in regulating our weight. Some suggest it plays no role at all, as the more we exercise, the hungrier we become.

Other people pointed to more obscure factors: adenovirus-36 infection, antibiotic use in childhood and endocrine-disrupting chemicals. While there is evidence suggesting they might all play a role, and while they could explain some of the variation in the weight gained by different people on similar diets, none appear powerful enough to explain the general trend.

So what has happened? The light begins to dawn when you look at the nutrition figures in more detail. Yes, we ate more in 1976, but differently. Today, we buy half as much fresh milk per person, but five times more yoghurt, three times more ice cream and – wait for it – 39 times as many dairy desserts. We buy half as many eggs as in 1976, but a third more breakfast cereals and twice the cereal snacks; half the total potatoes, but three times the crisps. While our direct purchases of sugar have sharply declined, the sugar we consume in drinks and confectionery is likely to have rocketed (there are purchase numbers only from 1992, at which point they were rising rapidly. Perhaps, as we consumed just 9kcal per day in the form of drinks in 1976, no one thought the numbers were worth collecting). In other words, the opportunities to load our food with sugar have boomed. As some experts have long proposed, this seems to be the issue.

The shift has not happened by accident. As Jacques Peretti argued in his film The Men Who Made Us Fat, we have been deliberately and systematically outgunned. Food companies have invested heavily in designing products that use sugar to bypass our appetite control mechanisms, and packaging and promoting them to break down what remains of our defences, including through the use of subliminal scents. They employ an army of food scientists and psychologists to trick us into eating more junk (and therefore less wholesome food) than we need, while their advertisers use the latest findings in neuroscience to overcome our resistance.

They hire biddable scientists and thinktanks to confuse us about the causes of obesity. Above all, just as the tobacco companies did with smoking, they promote the idea that weight is a question of “personal responsibility”. After spending billions on overriding our willpower, they blame us for failing to exercise it.

To judge by the debate the photo triggered, it works. “There are no excuses. Take responsibility for your own lives, people!”. “No one force feeds you junk food, it’s personal choice. We’re not lemmings.” “Sometimes I think having free healthcare is a mistake. It’s everyone’s right to be lazy and fat because there is a sense of entitlement about getting fixed.” The thrill of disapproval chimes disastrously with industry propaganda. We delight in blaming the victims.

More alarmingly, according to a paper in the Lancet, over 90% of policymakers believe that “personal motivation” is “a strong or very strong influence on the rise of obesity.” Such people propose no mechanism by which the 61% of English people who are overweight or obese have lost their willpower. But this improbable explanation seems immune to evidence.

Perhaps this is because obesophobia is often a fatly-disguised form of snobbery. In most rich nations, obesity rates are much higher at the bottom of the socio-economic scale. They correlate strongly with inequality, which helps to explain why the UK’s incidence is greater than in most European and OECD nations. The scientific literature shows how the lower spending power, stress, anxiety and depression associated with low social status makes people more vulnerable to bad diets.

Just as jobless people are blamed for structural unemployment and indebted people are blamed for impossible housing costs, fat people are blamed for a societal problem. Yes, willpower needs to be exercised – by governments. Yes, we need personal responsibility – on the part of policymakers. Yes, control needs to be exerted – over those who have discovered our weaknesses and ruthlessly exploit them.

www.monbiot.com

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