|
medpundit |
||
 |
 |
|
Wednesday, December 18, 2002Less than a quarter of the doctors think it would be very effective to use computers instead of paper forms to order drugs or to include pharmacists on hospital rounds, two approaches that have been shown to reduce medication errors in hospitals. Nor were they enthusiastic about using only specially trained physicians on intensive care wards, or about limiting high-risk medical procedures to hospitals that do a lot of them, despite evidence that expertise and frequent practice are key ingredients in successful medicine. Errors, regardless of how low their incidence, should be minimized. It would be wonderful if we lived in a perfect world where errors could be completely eliminated, but we don’t. And since we live in the real world, we should consider the consequences carefully of any steps we take to reduce errors. They may introduce errors of their own. Including pharmacists on hospital rounds, for example, may be an achievable goal in some situations - say in teaching hospitals where rounds are done by teams of residents and attendings at set hours of the day. But most hospitals aren’t teaching hospitals, and most rounds aren’t done by teams of physicians, but by the patient’s own attending physician. It would be impossible to coordinate the visits of every community physician to the hospital to see their handful of patients with the pharmacists’ schedule. I’d rather have the pharmacist in the pharmacy making sure drugs are mixed properly, or checking a database for potential drug interactions. Making the pharmacist abandon the pharmacy for rounds would be an extremely wasteful use of a pharmacist, even if you could coordinate his schedule with all of the rounding physicians at a hospital. Drugs aren’t ordered every day, or changed every day in most hospitalized patients. In most cases, rounds amount to monitoring the progress of a patient well on their way to healing. The intensivist issue is a little trickier. In large hospitals, intensivists make sense. Because they serve a large population, they have more critically ill patients, and having one or two physicians in charge working as a team with the nursing staff is a more efficient use of resources, and translates into better care, especially if the patient's primary care physician is included. But, not all hospitals serve large communities. There are plenty of small community hospitals far from a large city, where people end up needing short-term critical care - say a ventilator for pneumonia or emphysema, or they need stabilization in a critical care unit for a devastating illness before they can be safely transferred to the distant, larger hospital with its specialty care. In these situations, an intensivist isn’t necessarily a requirement, or even that much of an enhancement. He may, in fact, languish in a small community because his skills aren’t in much demand. A general internist, family physician, pulmonologist, cardiologist, or hospitalist with intensive care skills and experience could just as easily handle this sort of situation, and be more likely to survive financially since they provide other sorts of care as well. Then, there’s the issue of computers. Computers are wonderful. Their influence on our lives for the better can’t be denied. But they aren’t a panacea for every ailment. Errors are just as likely to occur when data is entered into a computer as when it’s written on an order form. It’s much harder to inadvertently handwrite a wrong number than it is to inadvertently enter it on a computer keyboard. The handwritten order has to be read and interpreted by another person, usually the nurse caring for the patient, who is more likely to notice an error than a computer system would. In the computer system, the order gets automatically translated into action by people who don’t know the patient at all. Consider the hospital error that happened to a patient I saw this past weekend. She was a patient of a colleague, admitted for pneumonia. When I went to see her on Saturday morning, she wasn’t in her room. The unit clerk told me she was getting an echocardiogram. That struck me as odd, because my colleague hadn’t mentioned it to me, and she hadn't mentioned anything that would warrant an echocardiogram. Maybe she forgot. Later, when the patient had returned, and I could look through her chart, I discovered that there was no order for an echocardiogram. What had happened was that the clerk entering the order into the computer had typed an “8” instead of a “9” when she was entering the room number. The order went down to the cardiac lab, who sent someone up to get the patient from that room. Luckily, an echocardiogram is noninvasive and painless and without risk. The only damage from doing it on the wrong person is that she might have to battle an incorrect hospital charge. But, the error wouldn't have happened in a hand written order. (It also wouldn't have happened if the computer system required both name and room number to enter an order.) The Times editorial is based on a study that appeared last week in the New England Journal of Medicine. (Unfortunately it’s only available online with a subscription). What the editorial doesn’t mention is that the public and physicians are on the same page when it comes to medical errors and their relative importance: Neither physicians nor the public named medical errors as one of the largest problems in health care today. The problems cited most frequently by physicians were the costs of malpractice insurance and lawsuits (cited by 29 percent of the respondents), the cost of health care (27 percent), and problems with insurance companies and health plans (22 percent). In the survey of the public, the issues cited most frequently were the cost of health care (cited by 38 percent of the respondents) and the cost of prescription drugs (31 percent). Only 5 percent of physicians and 6 percent of the public identified medical errors as one of the most serious problems. ...The majority of both physicians and the public believed that 5000 or fewer deaths in hospitals each year are due to preventable medical errors — a much lower number than either the high or low IOM estimate. A majority of respondents in both surveys thought that one half or fewer of these deaths could have been prevented. And it’s not only physicians who don’t agree with the solutions endorsed by the Times: Of the 16 proposed solutions, a majority of physicians thought that 2 would be very effective at reducing the number of medical errors: requiring hospitals to develop systems for preventing medical errors (55 percent) and increasing the number of nurses in hospitals (51 percent). A majority of the respondents in the survey of the public rated eight items as very effective. The top four items were giving physicians more time to spend with their patients (78 percent), requiring hospitals to develop systems for preventing errors (74 percent), providing better training of health professionals (73 percent), and using only physicians trained in intensive care medicine on intensive care units (73 percent). ...Seventy-one percent of physicians thought that an error would be more likely at a hospital that performs a low volume of procedures than at a high-volume center. The public was divided on this issue; about half the respondents thought that an error would be more likely at a low-volume center (49 percent), and the other half thought either that an error would be more likely at a high-volume center (23 percent) or that volume would make no difference (26 percent).... In neither group did a majority of respondents think that limiting certain high-risk procedures to high-volume centers would be a very effective way to reduce medical errors. The general public did feel that serious medical errors should be openly reported, whereas physicians didn’t. That’s understandable. Physicians are naturally suspiscious of state interference. Just coming to a mutually agreeable definition of what constitutes an error would be difficult. And a state system could prove to be unwieldy and punative. There isn’t a man who walks this earth who doesn’t make mistakes once in a while. But, patients deserve to know about errors. If not on a system-wide basis, at least on an individual basis. When errors are made in their care, the right thing to do is to admit to it, and face the consequences. You’d be surprised at how often those consequences turn out to be forgiveness. posted by Sydney on 12/18/2002 09:37:00 AM 0 comments 0 Comments: |
|
