Archive for the ‘Patient Safety’ Category

The New Enron? Are Hospitals Cooking the Books?

Thursday, April 28th, 2011

Tax season is over. Well, it is over if you filed your return in a timely fashion. Don’t let this blog stop you from stashing away your W-2’s and 1040-G’s for safekeeping. I hope you never need them. But, if you will, indulge me for just a second and leave your calculator out. No, I don’t need you to calculate the ever-increasing cost to fill-up your gas tank. Let’s take a quick look at a few health care statistics. Before you cringe, declare that you ‘hate math!’ and click-back to Facebook, let me share this with you: medical errors occur 10 times more than previously thought. Maybe that wasn’t hard hitting enough. Let me try again. How about this: mistakes occur in one out of every three hospital admissions!

Yes, seriously.

It’s Hard To Measure Without a Yardstick

Despite all of their education and training, medical professionals make mistakes. You know it, I know it, and certainly they know it. I hope that we can also all agree that it is unrealistic to expect for our health care providers to be perfect. What is reasonable, however, is to require an accurate accounting of the mistakes that occur in a health care setting. Believe it or not, there is no uniform method for a hospital to classify, track and otherwise determine what is or is not a medical mistake. A negative outcome at Hospital X in Baltimore might be considered a mistake, and yet if the same negative outcome occurred at Hospital Y in Washington D.C., it would not be considered a mistake. How so?

I don’t want to bog you down with the myriad measures that hospitals use to come up with the numbers but suffice it to say that at any hospital in the United States, its administration could utilize the: Agency for Healthcare Research and Quality’s Patient Safety Indicators or the Utah/Missouri Adverse Event Classification technique, or an approach developed by the Harvard Medical Practice Study, or the Institute of Healthcare Improvement’s Global Trigger Tool, or they can do their own analysis of the records and score themselves (self-reporting.)

That was a mouthful. Essentially, a yardstick for measuring the safety of care in hospitals does not exist. Or, at least, a yardstick has not been agreed upon. The two most common methods used, however, are voluntary reporting and the Agency for Healthcare Research and Quality Patient Safety Indicators. And according to a recent study, those two methods are awful. Before you conclude that I am being too harsh, let’s take a look.

The Good, the Bad, and the Ugly

The study, conducted by David C. Classen, and published in journal Health Affairs, utilized the Institute for Healthcare Improvement’s Global Trigger Tool. The Global Trigger Tool uses specific methods for reviewing medical charts. Patient charts are analyzed methodically, analyzing discharge codes, discharge summaries, medications, lab results, operation records, nursing notes, and physician progress notes to determine whether or not a “trigger” exists. A notation of a trigger leads to further investigation into whether or not an adverse event occurred. Here is how the tools stack up:

Self Reporting (Commonly Used Method #1): 4 adverse events detected

Safety Indicators (Commonly Used Method #2): 35 adverse events detected

Global Trigger Tool: 354 adverse events detected

The Global Trigger Tool is overwhelmingly more sensitive and picked-up many, many more adverse events. Overall, the Global Trigger Tool discovered that adverse events occurred in 33.2 percent of hospital admissions or 91 events per 1,000 patient days. That number is staggering.

What kind of “adverse events” are being missed? Medication errors, surgical errors, procedure related errors, infection, pressure ulcers, device failures and patient falls. All very serious and potentially injurious to a patient. The study indicates that the error detection tool being utilized by Hospital ABC in Yourtown, USA is probably woefully inadequate.

Why Accurate Error Detection Is Important

Error detection is essential to error correction. A hospital cannot identify the areas that need improvement if it is unable to identify the areas where it is falling down on the job. Failure to utilize an adequate error detection tool ensures that the same mistakes will continue to happen time and time again. I think the results certainly beg the question: why not adopt a nationwide standard? The Global Trigger Tool or another sensitive measuring matrix strikes me as a reasonable place to begin.

Certainly, there is a financial aspect to this discussion. Extensive chart reviews and lengthy inquiries into negative outcomes are costly and time intensive. Also, what motivation, besides error prevention, does a hospital have to discover its errors? As I wrote about here before, when errors are discovered, hospitals are penalized. If a hospital’s main concern is its bottom line and not patient safety, why not continue to “self-report” or use the Agency for Healthcare Research and Quality Patient Safety Indicators and leave the adverse events undetected?  Makes sense if you want to avoid the penalties…

It doesn’t say “leave a response” down below for nothing. Feel free to let us know YOUR thoughts.

QUESTION: Have you ever had a negative outcome at a hospital? Where you told that a mistake was made or were you told otherwise?

 

Week in Review (April 18 – 22, 2011) The Eye Opener Health and Law Blog

Saturday, April 23rd, 2011

From the Editor:

This past week, our blawgers (guess I’ll use this term now since we are legal bloggers) were busy on their keyboards once again. They covered a number of topics relating to law, medicine, health and patient safety. This week we posted a primer on aortic aneurysms and how they can present as back pain, a blog about “robot” anesthesiology, a disturbing post about how the recent threat of a federal government shutdown was averted but at a cost to those who are in dire need of healthcare, an interesting piece about laughing gas making its way back into the American medical scene for labor and delivery and finally, and a highly read piece on a not-to-often discussed topic but one of potential grave concern – shift switching by nurses and how this might impact patient safety.

Here’s our usual “quick summaries” for you to peruse, click on, read and comment:

Aneurysms – a deadly condition you need to know about!

Our in-house medical specialist, Theresa Neumann, wrote another highly educational and need-to-know piece about a condition that can present as back pain but which has deadly consequences for those who have this condition.

As Theresa’s research made us aware – “1 in every 50 males over the age of 55 have an abdominal aneurysm, this is a more common pathologic diagnosis than some others.  Men also corner the market at an 8-to-1 ratio as compared to women with abdominal aneurysms.”

As is the case with all of Theresa’s writings, we offer through her valuable information from someone who’s “been there” and “done that” in the clinical setting. Don’t miss her post entitled Aneurysms: A Potential Deadly Condition That May Present as Back Pain.

Who’s using remote control and a joy stick to put a breathing tube down your throat?

Mike Sanders brought to our attention a new practice of anesthesiologists – in Canada – that may soon be part of anesthesia management in the United States as well – using robotics to intubate patients. While you can certainly learn about the concept of intubation by reading Mike’s blog, basically, this is placing a small tube down a patient’s airway so that the anesthesiologist can control the airway and provide ventilation to a patient undergoing surgery.

Here’s an except -

Medical News Today is reporting that Dr. Thomas Hemmerling of McGill University and his team have developed a robotic system for intubation that can be operated via remote control.

For more on this fascinating new project by Dr. Hammerling and his team, read Mike’s post entitled Robot Anesthesiologists?

Government Shutdown Avoided – but who will pay the price for the “deals” that were cut?

The newest member of our blogging team, Jason Penn (fast approaching veteran blawger status) did a fascinating piece of the story-behind-the-story of the recent crisis our country faced when the federal government was on the verge of a shutdown. We all know about deals being cut in the back rooms of congress. We all know that the government avoided a shutdown this time around when the senate and house worked out a compromise that resulted in millions of dollars being earmarked for cuts in the budget.

Jason tells us what programs relating to healthcare will suffer as a result of these negotiated cuts. As some wise person once said, “why is it always those who are least represented who bear the burden of budget cuts?” Maybe it’s because they can’t afford lobbyists to protect them like those who need protection the least can.

Read Jason’s eye opening and no-punches-pulled report on just who will be the victims of the deals in his post of this past week Budget Crisis Avoided, But What About the Babies? Can They Live With $504 Million Less in Funding?

Will moms-to-be now be “laughing” their way through labor and delivery?

One of our seasoned blawgers, who every now and then is driven to report on the off-beat issues of law, medicine and healthcare, Jon Stefanuca, stepped up to the plate once again and took a swing at the return of an old-timer to the arsenal of pain relief for mothers-to-be undergoing labor and delivery – laughing gas!

As Jon’s piece in Eye Opener this past week tells us -

It appears that a number of hospitals are now considering making laughing gas available as a pain relief measure for women in labor. A hospital in San Francisco and another in Seattle have been using laughing gas in their labor and delivery units for a while. Hospitals like Dartmouth-Hitchcock Medical Center plan to offer laughing gas to laboring mothers in the immediate future.

For more about this return of laughing gas to our obstetrical units, read Jon’s piece Laughing Gas Making Its Way Back Into the Labor and Delivery Department.

Nursing and Sleep Deprivation: Is it a risk factor for patient safety?

I suspect somewhere along the line you have done “an all-nighter” – whether it was getting ready for a big test, a social event, or for some other reason. Remember how you felt as you made it through that night or the next day? Have you ever done it several nights in the same week? How about doing it a few times one week and then do the same thing the next week and the next…. Well you no doubt get the idea. You’ve been exhausted, right? Well what about nurses, who have to do this for a living?

Nurses have lives too. They have children, home responsibilities and obligations, and some form of social life. What happens when they swap shifts or are asked to do “a double”?

Sarah Keogh was back blogging this past week and wrote a fascinating (and concerning) post entitled Nurses Switching Shifts: Does a Lack of Sleep Put Patients at Risk? We invite you to read Sarah’s piece and share your comments. Are you a nurse who lives this lifestyle? What are your thoughts about nurses being allowed to work multiple shifts or back-to-back shifts in terms of patient safety? Should there be restrictions on nurses’ shifts just as there (finally) are work restrictions on doctors-in-training?

A “Sneak Peak” of the week ahead

As part of our continuing effort to “get the word out there” on issues relating to health, medicine, patient safety and the law, we post from time to time more extensive research pieces called White Papers. Well, the time has arrived for another White Paper to be posted on our website. Marian Hogan has completed her piece on a very important topic – Patient Controlled Analgesia in today’s hospital environment. She examines how some hospitals are now heavily marketing a spa-like environment so you choose them over the competition. Yet lurking in the shadows of these facilities which promote flat screen TV’s, valet parking, in-room safes and the like is a very dangerous practice: placing patients on patient-controlled-analgesia (for pain relief) without vital monitoring devices and patient safety practices. It’s at the “printer” now; we hope to have it online this week.

From our blawgers you can expect reports on a disturbing fight between manufacturers and child safety experts over – blinds! After decades of controversy, you’ll find out where the battle lines are now drawn, who’s winning and who the real losers are in this war. Wonder how healthcare safety is doing since the report To Err is Human was published by the Institute of Medicine over a decade ago? Jason Penn will be providing an updated report card, which you should not miss. Alcohol and surgery – not a good combination! Jon Stefanuca plans on posting a piece that looks deeper in the obvious problems with this potentially deadly combination.

This is just a taste of what’s to come. I better wrap-up now. I’m working on finishing the third installment on Medical Technology and Patient Safety. Oh yeah, if time permits, I might even get to post a piece I’ve been working on this past week – a lawyer’s rant about our modern day love affair with mediation practices and trends.

As always, don’t forget - subscribe to the Eye Opener and tell your friends about us too! …and… don’t forget to join our social networking communities on Facebook and Twitter.

Hope you have a great weekend!

Nurses Switching Shifts: Does a Lack of Sleep Put Patients at Risk?

Friday, April 22nd, 2011

Image from scrubsmag.com

Many of us take it as a given that if we end up in a hospital, we will be taken care of by an around-the-clock group of health care professionals. These doctors, nurses and other staff will be awake and alert to care for us and prevent any potential problems during our stay. However, how many of you have thought about how this impacts these health care professionals on their days off? I know that I had not thought too much about this issue. I had taken for granted that if I or a loved one were hospitalized that the professionals involved in their care would be at least well rested enough to avoid major medical errors.

I have read lots of different reports about all of the rule changes for doctors in training regarding how many hours they can work in a week or at one time. I had never before read a report regarding the impact of work schedules on nurses. While I knew that most nurses worked 12-hour shifts, I have to admit that I had not thought about how this impacted their own lives or patient care. That changed when I read a recent article in medicalnewstoday.com. This article discusses a study published in Public Library of Science One that was conducted “…to examine the strategies that night nurses use to adjust between day and night sleep cycles.”

What seems obvious in retrospect, but that I had never really considered before, is that nurses who work the night shift (typically 7 pm until 7 am – or “7p to 7a” as they like to call it), normally do not stay up all night in their “non-work” lives. On their days off, they often want to live a more typical life with daytime awake hours. The ramification of this is that they need to switch their sleep schedule back and forth several times throughout the week. Can you image having to do that yourself and still perform your job properly?

The medicalnewstoday.com article explains that “[a]s many as 25 percent of hospital nurses go without sleep for at least 24 hours in order to adjust to working on the night shift, which is the least effective strategy for adapting their internal, circadian clocks to a night-time schedule.”

The “First Shift” Effect

So, the first issue in this revelation is that as many as a quarter of hospital nurses are going without sleep for at least 24 hours when adjusting to working the night shift. I shudder to think of how many nurses around the country are therefore working at least their first night shift every week while on hours 12-24 of not having slept.

While others may function better than I do without sleep, I don’t think that I would ever feel comfortable being cared for by a nurse who had not slept in the prior 12 hours before starting their shift. It seems to me that this opens up the possibility for many medical errors and patient injuries.

The Circadian Clock Effect

The second issue I had was that this is also “the least effective strategy for adapting their internal, circadian clocks” – which I take to mean that if a nurse who has not slept for that first shift is not bad enough – it also does not work very well to help them be adjusted and well rested for the rest of the week.

If the concerns about the health of the public being cared for by tired nurses is not bad enough, this can also be quite damaging to the health of the nurses themselves. These selfless individuals who are caring for others are – frankly – at risk.

A number of previous studies have found that repeated incidence of circadian misalignment the condition that occurs when individuals’ sleep/wake patterns are out of sync with their biological clocks is not healthy. Jet lag is the most familiar example of this condition. Circadian misalignment has been associated with increased risk of developing cardiovascular, metabolic and gastrointestinal disorders, some types of cancer and several mental disorders.

So, these nurses are risking their own health in addition to potentially the health of their patients.

Just how important is sleep?

Just how much does sleep matter? Well, another article from medicalnewstoday.com recently looked at sleep in a very different context. It examined a study from the Journal of Clinical Sleep Medicine, which showed that “…automobile crash rates among teen drivers…” were dramatically higher in otherwise similar school districts where teens started school earlier in the morning (a difference of about 1 hours and twenty minutes). While there is no proof yet that this connection is causal, there certainly seems to be a strong connection even after adjusting for other possible factors. The article also mentions that:

Another study in the April issue of the Journal of Clinical Sleep Medicine suggests that delaying school start times by one hour could enhance students’ cognitive performance by improving their attention level and increasing their rate of performance, as well as reducing their mistakes and impulsivity. The Israeli study of 14-year-old, eighth-grade students found that the teens slept about 55 minutes longer each night and performed better on tests that require attention when their school start time was delayed by one hour.

While teens and teenage behavior can be different from that of adults (thank goodness), I still think that these studies highlight some of the key issues of sleep deprivation. Adults seem likely to also make more mistakes, lack attention and act more impulsively when functioning on less sleep.

However, a review of a study from Nursing Economics entitled “Shift Work in Nursing: Is it Really a Risk Factor for Nurses’ Health and Patients’ Safety” suggests that other factors put nurses’ health at greater risk and that shift work does not impact the number of medical errors. The study was conducted in Israel in 2003. It is important to note that this study looked at nurses working alternating 8-hour shifts and did not directly look at the issue of nurses not sleeping in order to switch between 12-hour shifts.  The investigators in the study were surprised by some of their findings:

Shift work and organizational outcomes. In the present study, we investigated the impact of sleep disturbances on shift nurses and on two organizational outcomes: errors and incidents and absenteeism from work. Based on our literature review (Morshead, 2002; Muecke, 2005; Westfall-Lake, 1997), we expected that “non-adaptive shift nurses” would report on more involvement in errors and adverse incidents as compared to “adaptive shift nurses.” We also assumed that non-adaptive nurses, who by definition have more sleep-related complaints, would have higher absenteeism rates due to illness compared to their adaptive colleagues. Neither of our hypotheses was supported by the results of this study.

Instead the study found that:

It appears that gender, age, and weight are more significant factors than shift work in determining the well-being of nurses. Moreover, nurses who were identified as being non-adaptive to shift work based on their complaints about sleep were found to work as effectively and safely as their adaptive colleagues in terms of absenteeism from work and involvement in professional errors and accidents.

What do you think? Would you want a nurse who has been up for 24 hours to be caring for you or your loved one? Should it be the nurse’s decision whether they are alert enough for work? Should rules be created for nurses just as they were for physicians in training? What about nurses who enjoy the flexibility and freedom allowed by this sort of schedule? Have you worked as a nurse? What are your experiences and feedback on whether this is a problem?

Related Post – you may want to read:

A Surgeon’s Sleep Deprivation and Elective Surgery – Not a good (or safe) combination.

The New England Journal of Medicine published a Perspective on December 30, 2010, that screams common sense and should be embraced as a starting point to implement some new patient-safety standards of practice. Place yourself in the position of a patient getting ready to undergo an elective (i.e. non-emergency) surgical procedure. You’re wheeled into the operating room for your surgery and are greeted by your surgeon in the process. Read more…


 

Laughing Gas Making Its Way Back Into The Labor And Deliver Department

Thursday, April 21st, 2011

According to a recent article published by MSNBC, laughing gas or nitrous oxide is making its way back into labor and delivery units in American hospitals. Although laughing gas has long been used as a pain relief in various countries, including Canada and the U.K., it has lost its popularity in the U.S. Well, maybe not for much longer.

It appears that a number of hospitals are now considering making laughing gas available as a pain relief measure for women in labor. A hospital in San Francisco and another in Seattle have been using laughing gas in their labor and delivery units for a while. Hospitals like Dartmouth-Hitchcock Medical Center plan to offer laughing gas to laboring mothers in the immediate future. Dartmouth-Hitchcock’s plan is currently being reviewed by the federal government, and arrangements are presently being made for the procurement of delivery equipment for laughing gas. Vanderbilt University Medical Center may begin offering laughing gas as well later this year.

History

Laughing gas is not a new pain relief method. Its use had become very common in hospitals when Joseph Thomas Clover invented the gas-ether inhaler in 1876. Particularly, its use in the labor and delivery setting had been very common before the introduction of epidural and spinal anesthesia. Because laughing gas is unable to eliminate pain to the same degree as epidural or spinal anesthesia, it simply could not compete with the more sophisticated pain relief alternatives, which entered the marker in the 30s and 40s.

What is laughing gas?

Nitrous oxide, commonly known as laughing gas or sweet air, is a chemical compound with the formula N2O. It is an oxide of nitrogen. At room temperature, it is a colorless non-flammable gas, with a slightly sweet odor and taste. It is used in surgery and dentistry for its anesthetic and analgesic effects. It is known as “laughing gas” due to the euphoric effects of inhaling it, a property that has led to its recreational use as a dissociative anesthetic.

Laughing gas as an important pain relief alternative

Although laughing gas can only take the edge off pain, it just might be an important alternative to other more conventional pain relief methods. The patient does not have to rely on an anesthesiologist to administer the gas. The patient can herself choose how much gas to administer at any time. The effects of the gas are not long-lasting. Therefore, the patient does not have to recover in a post anesthesia care unit. Importantly, there is no associated loss of sensation and motor function during the delivery process. As such, the gas does not interfere with the woman’s ability to breath and push during labor. Laughing gas is also not known to have any adverse effects on the baby in utero.

The administration of laughing gas does not require any invasive medical procedures. By contrast, consider epidural anesthesia: An epidural requires that an epidural catheter be threaded into the epidural space, which is only about 2 mm wide. Any mistake and the consequences can be catastrophic. Epidurals have been known to cause spinal cord injury secondary t0 toxicity, spinal cord infarcts, severe hypotension, paraplegia, epidural bleeding, and even death. None of these complications are associated with the use of laughing gas.

: httpv://www.youtube.com/watch?v=1TO4sOgiIeU]

According to Suzanne Serat, a nurse midwife at Dartmouth-Hitchcock Medical Center:

We have a number of people who don’t want to feel the pain of labor, and nitrous oxide would not be a good option for them. They really need an epidural, and that’s perfect for them. […] Then we have a number of people who are going to wait and see what happens, and when they’re in labor, decide they’d like something and then the only option for them is an epidural but they don’t need something that strong. So they would choose to use something in the middle, but we just don’t have anything in the middle.

Nitrous oxide may just prove to be that middle option for many women who prefer to give birth without the use of powerful and potentially dangerous analgesic/anesthetic agents. If you are an expectant mother, ask your obstetrician if nitrous oxide is a pain relief option that may be available to you during labor.

Image from cartoonstock.com

For more information about epidural anesthesia and epidural complications, you may want to read these posts too:

Having an epidural when you deliver your baby? 3 Questions to ask the doctor!

5 Questions to Ask Your Obstetrician Before You Go to the Hospital

Epidural Analgesia – What Should an Expectant Mother Consider? What are the risks?

Week in Review: Miss our posts this past week? Catch-up now!

Saturday, April 16th, 2011

From Eye Opener’s Editor, Brian Nash: Another week gone by – where does the time go? Our bloggers this past week, Theresa Neumann, Jon Stefanuca, Jason Penn, Mike Sanders and Sarah Keogh, were – in addition to practicing law – busy on the keyboard blogging away. In case you missed any posts during the week of April 10th through the 15th, here’s your opportunity to catch-up.

The “Medical Home” – find out what it is and why you should have one!

This past week, Sarah wrote two blogs on a concept that frankly I had not heard of before – the Medical Home. Her follow-up piece on how parents in particular are using emergency departments and clinics was posted yesterday, Friday, April 15th.

In her first piece, Sarah discussed a key issue about continuity of medical care for all of us but particularly our children. While there’s no doubt that there are times when taking your child to an emergency room is the only way to go in a true emergency, is it really the right place for a child to receive primary care? You see a physician or a medical specialist such as a physician’s assistant on a one-time basis. What do they really know about your child’s complete medical history? Do they really address key issues of general health care that is essential to your child’s overall health?

Her second post addresses specifically the topic of how many in this country are using facilities such as in-store clinics and emergency rooms for minor, non-emergency care. While there is no doubt that ED’s and clinics serve a vital role in the providing of healthcare in the United States, are they being used the right way? Are clinics often the only place where many in our country can obtain care for their children? Read Sarah’s posts on What is a medical home? Do your children have one? and her follow-up piece Clinics and Emergency Rooms: Helpful or Barriers to Good Pediatric Care.

A Disturbing Report on Some Area Hospitals and their Complication Rates

Earlier in the week, the new member of our legal team, Jason Penn, wrote about a recent report from the Maryland Health Services Cost Review Commission regarding a continuing failure of several local Maryland and DC hospitals to lessen the number of patients who suffer from complications while in these institutions. P.G. Hospital Center won the dubious distinction of being first in class. Jason reports that this institution, which services many of the area’s population, was fined by the state of Maryland for the number of “complications that are unlikely to be a consequence of the natural progression of an underlying disease.” The “list” includes specified complications such as “bed sores, infections, accidental punctures or cuts during medical procedures, strokes, falls, delivery with placental complications, obstetrical hemorrhage without transfusion, septicemia, collapsed lungs and kidney failure.” For information as to how the local jurisdictions deal with these hospitals in the pocketbook and who made the list, read Jason’s blog post entitled Report Card on Failing Hospitals: Prince George’s Hospital Center Tops “Complications” List.

Learn More about Medicine and Your Health

Theresa Neumann, an in-house medical specialist in our firm, posted Spinal Stroke: An atypical cause of back pain this past week. It’s one thing to have lawyers who live and breath medicine and the law write about medical conditions; it’s quite another to have real medical specialists like Theresa educate all of us on medical matters that affect the lives of so many. Theresa brings to the public’s awareness the signs, symptoms, risks and potential treatment alternatives to a catastrophically disabling condition that many just don’t know about – until it’s too late for them.

We’ve all – unfortunately – heard about or know someone who has suffered a stroke in their brain. Well, as Theresa reports, there’s an equally devastating form of stroke that can hit our spinal cord, which can render the victim paralyzed, without control of bowel or bladder, incapable of feeling sensation and a host of other life-altering consequences. We’re always appreciative of the wonderful, educational pieces Theresa brings to our blog. This piece is no exception.

The War against Super Bugs – MRSA and CRKP – are we losing the fight?

There was a time many months ago where we all became aware of the super bug infection known as MRSA. It was in the news over and over again. Have you heard much about it lately? Silence by news media might make one think that our medical institutions have won the war and the threat of this deadly infection is over. As Mike Sanders tells us – not so quick! In his blog of this past week, Deadly Super Bugs on the rise, Mike tells us who’s winning the MRSA war to and about a newcomer in the Super Bug family – CRKP.

The news is simply not good! See what seems to be working against MRSA and don’t miss the update at the end of Mike’s post about a new prevention method using honey.

Law and Medicine

Well we are lawyers – so why not a piece about our specialty area – representing patients and families of patients against healthcare providers? This past week, Jon Stefanuca wrote what we consider to be a very important piece entitled Should you sue a healthcare provider? Some guidelines to help you decide.

Some may just be surprised about the advice Jon gives in this posting. It is not a call to arms against the medical profession or even a call to our law firm so you can sue the b*****ds! Jon offers some very important advice to those who have been through an experience with a healthcare provider and are considering whether or not they have a potential lawsuit for the injuries they have suffered.

We believe this post encapsulates in large part some principles we have been advocating for a long time. Not every bad outcome means malpractice has occurred. However, how would you – as a lay person – be able to make the distinction between what is and what is not a real medical malpractice case? In addition to Jon’s sage advice, this post links to a White Paper we did on Choosing a Lawyer – a Primer. We hope if you have unfortunately found yourself faced with this issue of whether you should sue or not that you will find this blog by Jon informative and helpful in making your decision.

A Sneak Peak of the Week Ahead

As you can see, our bloggers were quite busy last week. Well, this coming week will be no different. The days ahead will be consumed with representing our clients in depositions, investigations, filing pleadings and court appearances….and writing and posting some interesting, important blogs on aneurysms (did you know they can present as back pain?), laughing gas coming back for moms in labor, sleep deprivation for nurses (and how well that plays out in your healthcare) and some other good stuff our writers are busy working on this weekend and during the week ahead.

Stay tuned – stay informed! Read the Eye Opener and tell your friends about us too! …and don’t forget to join our social networking communities on Facebook and Twitter.

Clinics and Emergency Rooms: Helpful or Barriers to Good Pediatric Care?

Friday, April 15th, 2011

Image from: denverpost.com - (Photo: istock.com | Photo illustration: Linda Shapley, The Denver Post )

In my last post, I discussed the idea of a medical home and the comprehensive healthcare it is meant to provide. For families for whom insurance, work scheduling or other demands make seeing a doctor during regular office hours difficult, many turn to retail based clinics or emergency rooms to fill-in and provide care. Whether this is in addition to or instead of a primary care provider, it is a reality that many families are using clinics and emergency rooms to fulfill at least some of their healthcare needs.

The difficulty with receiving care in these settings, as opposed to a true medical home, is that the health care providers in these settings do not have a complete medical history or record. Each time there is a problem, a different health care provider is likely to provide care and therefore, the continuity of care is lost. Moreover, if there is a bigger problem or a bigger picture issue for the patient or family, the health care provider is really not able to help make the diagnosis and assist in formulating a care plan. Recently, I have come across a number of interesting articles,which examine some of the other pitfalls of using retail clinics or emergency rooms for care, particularly for children. Their observations and opinions are well worth sharing.

In a recent blog article on kevinmd.com, Dr. Roy Benaroch discusses a variety of reasons why – for good pediatric care – you should avoid retail clinics . He highlights the potential conflicts of interest that exist when a clinic is within a store that also sells prescriptions. He defines good pediatric care as:

Care that looks at the whole child, the whole history, and the whole story. To do a good job I have to review the history, the growth charts, the prior blood pressures, the immunization records, and more. Good care means I’m available for every concern—not just the sore throat, but the “Oh, by the way…” worries that are often more significant than the current illness. Things like “He’s not doing so well in school,” or “I think he looks clumsy when he runs,” or “What am I going to do about these headaches every day?” Every encounter is a catch-up on problems and concerns from before, to be reviewed and updated. Children are growing and developing, and every encounter is a snapshot of their over all well-being that can only make sense if it can be placed into a continuous album. At the retail-based clinic, the encounters are just a quick toss-off: an opportunity for genuinely improving health that’s thrown away.

He also points out the need for providers to be specialized in pediatrics and to be up-to-date on current medical recommendations. Providers in these clinics may be generalists and not up-to-date in the specifics of care for children.

A recent article in the New York Times highlights one potential hazard for children visiting emergency rooms for care – the increased use of CT scans. The article reports that the use of CT scans for children visiting emergency rooms has increased fivefold between 1995 and 2008, such that almost six percent of children visiting the emergency room for care are now receiving the scans. There are benefits and detriments to this increase:

…advances in the technology had resulted in improved image quality that can greatly aid diagnosis of childhood ailments. But the scans expose patients to high levels of ionizing radiation that can cause cancer in later years, and radiation is even more harmful for children than for adults.

The New York Times article goes on to explain that risks are low and the patients who need the scans should receive them. However, it raises an important question in my mind.

The article states that the scans are most often given for “children arriving with head injuries, headaches or abdominal pain.” Certainly, there are plenty of times when a child may visit an emergency room for a true emergency and a CT scan, if warranted, should be done without delay. But, I wonder whether there are also situations in which a child may be visiting an emergency room because of a headache or abdominal pain, which has been persistent and would likely receive a different approach to treatment if first presenting in the child’s medical home rather than an emergency room. In that setting, would a doctor, with the child’s complete history and without other emergencies pressing, chose alternative diagnostic options before ordering a CT scan. The CT scan might still be warranted, but perhaps not as frequently. I am not a medical professional and would not question the judgment of a medical professional, but generally speaking, the value of consistency of care with a primary provider seems prudent whenever it is an available option.

From a personal perspective, I understand that even parents who are the most attuned to the desire for continuous care may waiver when faced with a child in pain during off-hours. Parents who are unable to get their child to the doctor during work hours or whose child suddenly has pain at 9 pm (or 3 am) are faced with an unfortunate decision. While I certainly would take my child to an emergency room for a true emergency, I have chosen many times to wait for our doctor’s office to open in the morning rather than take them to a 24 hour clinic for a non-emergency case of extreme ear pain or similar problem. It is horrible to wait those hours with a child in discomfort; however, I know that in the morning a doctor who has the complete history of the problem will then address the problem. Just this week, I was grateful – again- that we are lucky enough to have a primary care pediatrician, who knows our child,  is comprehensive enough to care for our children, and by seeing “the big picture” can coordinate care immediately with specialists whenever that is warranted.

To me, a physician I can trust, coupled with great practice management, is essential to a pediatric practice where I can feel comfortable taking my kids.  What are some of the things you most value? What about adult primary care providers – are you using clinics and emergency rooms for your primary care or do you have and prefer the continuity of care provided by your personal primary care physician?

What is a “medical home”? Do your children have one?

Thursday, April 14th, 2011

Image from www.hi-consulting.net

What is a “medical home”? Do you feel like you or your children have a medical home? Is it one that feels comfortable and accessible and all of the things the term “home” implies?

A couple of years ago, I was involved in some policy work surrounding the idea of the medical home and how to better ensure that children in Baltimore City had a medical home. When I first became involved in this project, I thought I understood the concept of a medical home, but I could not really define it. Working with a group of professionals from medical, public health and policy backgrounds, we spent several months furthering our understanding of what is a “medical home” before we could determine how to measure if children had adequate medical homes.

Today, I am not going to delve into that kind of detail about this topic. However, I thought it might be interesting to think about the concept of a medical home and some of the benefits and potential challenges this poses for families.  In this post, I’ll provide some definitions of “medical home” and provide some information about how many children are receiving care in a medical home.  I’ll address this topic in a future post about alternative health care locations.

I think that the idea of a medical home speaks to an often forgotten concept in providing the best health care with the fewest mistakes – consistency of care from a committed health care provider. The National Center for Medical Home Implementation, which is “a cooperative agreement between the Maternal and Child Health Bureau (MCHB) and the American Academy of Pediatrics (AAP)”, has a website full of information about the medical home. Their definition of medical home is:

A family-centered medical home is not a building, house, hospital, or home healthcare service, but rather an approach to providing comprehensive primary care.

I think that this is a great overview of the concept. The definition continues:

In a family-centered medical home the pediatric care team works in partnership with a child and a child’s family to assure that all of the medical and non-medical needs of the patient are met.

Through this partnership the pediatric care team can help the family/patient access, coordinate, and understand specialty care, educational services, out-of-home care, family support, and other public and private community services that are important for the overall health of the child and family.

The American Academy of Pediatrics (AAP) developed the medical home model for delivering primary care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective to all children and youth, including those with special health care needs.

I think that we all hope that our health care is provided in a comprehensive way such as is described by this definition. However, too often, we all know that medical care is provided in a more complex web of services in which the patient or patient’s family is left to coordinate care. This reality is even more vivid for those families who are uninsured or under-insured and are not able to receive all of their care from a primary care provider who is able to best coordinate their care.

An article in Bloomberg Business Week reports that a new study found that “Children who have a “medical home” – that is, a pediatrician or nurse they see regularly who offers comprehensive care — are more likely to have their medical and dental needs met…” However, the article goes on to say that children “…who have a chronic condition or special need and require the most care” are the least likely to have a medical home. The article states that only 57% of children in this country “…received care in medical homes in 2007…”  The study also found that:

Younger children were more likely to have a medical home than older children.

There were racial and ethnic disparities as well: White children were the most likely to have a medical home, while Hispanic children were the least likely, followed closely by black children.

Mothers without a high school education were significantly less likely to report their children had a medical home, as were the poor, non-English speaking families and the uninsured.

About 61 percent of children whose parents said they were in excellent or very good health had a medical home, compared to 35 percent of kids in fair or poor health.

These children, who are most likely to need a medical home, are the least likely to have one. This is despite research, and common sense, showing that medical homes are able to provide better health care at lower cost. The Bloomberg article says that  “[c]hildren without a medical home were three to four times more likely to have an unmet medical or dental need, according to the study, published online March 14 in the journal Pediatrics.”  Additionally, “[c]hildren who received care in medical homes were also more likely to have annual preventive medical visits, the study found.”

As I was reading these statistics, I was imagining the children without a medical home as children who often used clinics or emergency rooms for their health care. However, the Bloomberg article says that the study found that

…nearly all children — 93 percent — had a usual source of care, and about the same number had a personal physician or nurse. About 82 percent of parents said they had few problems obtaining referrals, 69 percent said they received help with coordinating care when needed and 67 percent said they received family-centered care.

But only 57 percent of parents reported that the health care their children received met all of those criteria — the definition of a medical home.

It is the comprehensive care provided by all of the elements of the medical home that create the best results in terms of patient care and cost savings. It is this combination that is lacking in many providers of pediatric care.

Do the members of your family receive their care in a medical home? Could you answer yes to all of the questions above defining a medical home? Is this important to you? What would make it easier for you to receive this kind of care for yourself or your child?

 

Report Card on Failing Hospitals: Prince George’s Hospital Center Tops ‘Complications’ List

Tuesday, April 12th, 2011

From the Editor (Brian Nash):

The following is the first of many blogs-to-come by our new associate lawyer, Jason Penn. Read about Jason’s background and enjoy reading his first venture into the blogosphere of medicine-law-healthcare.

By: Jason Penn

Prince George’s Hospital Center finds itself at the top of yet another dubious list.  With 4 out of every 1,000 patients experiencing a complication, Prince George’s Hospital has failed to meet a target for the prevention of complications set by the Maryland Health Services Cost Review Commission.

The penalty for Prince George’s Hospital?  The hospital’s ‘rate increase’– or how much the hospital can charge for services rendered — will be lowered by $890,000 for next year.  The State uses a payment-related methodology to reduce the frequency of hospital-based complications.  The State of Maryland has the authority to establish hospital payment levels applicable to both private insurance companies and public insurers such as Medicare and Medicaid.  The methodology links payments to hospital performance on a list of 52 acquired conditions.  These conditions are complications that are unlikely to be a consequence of the natural progression of an underlying disease.  The program seeks to eliminate some of the most serious and injurious patient complications in Maryland’s 47 acute care hospitals:  bed sores, infections, accidental punctures or cuts during medical procedures, strokes, falls, delivery with placental complications, obstetrical hemorrhage without transfusion, septicemia, collapsed lungs and kidney failure.

The Maryland Hospital Acquired Conditions Initiative, begun in 2009, is an effort to tie financial incentives and penalties to how well hospitals perform in reducing life threatening, dangerous and preventable complications.  Maryland’s motivation in starting the initiative is not pure; rather, as the Commission’s name suggests, it is a cost savings measure.  Patient safety taking an apparent backseat, the Commission recognized that many of the complications that occur in the hospital setting are costly, to the tune of $521 million in 2010.

Prince George’s Hospital Center is not alone, however.  Eight other Maryland and Washington D.C. area hospitals will face penalties for complications.  Doctors Community, Washington Adventist, Montgomery General, Shady Grove Adventist, University of Maryland Medical Center, St. Joseph Medical Center, and Civista Medical Center of Cumberland, Maryland have been penalized due to their failure to meet targets for the prevention of complications.  Those hospitals will lose a combined $2.1 million in the amount they can charge patients, according to a story first reported by Kaiser Health News.

The Commission’s Executive Director Robert Murray noted in a news release that in fiscal year 2008, the Commission estimated preventable, hospital-based complications were seen in “55,000 of the State’s total 800,000 inpatient cases,” representing $522 million in hospital payments that could have potentially been avoided.  The number of complications is staggering:  The University of Maryland Medical System had an observed number of complications of 1223 cases; Prince Georges Hospital had 553; while Montgomery General Hospital had 304 listed.  All three hospitals were worse than the state average.

In the original Kaiser Health article, Mr. John O’Brien, president of Prince George’s Hospital noted that “the problem mainly lies in how the hospital tracks, codes and reports data, not in patient care.”

One thing seems certain – Prince George’s Hospital is failing.  The numbers certainly suggest that it is failing in its patient care responsibilities yet Mr. O’Brien reports that it is merely a “failure of its tracking system.”  If, theoretically, it is as Mr. O’Brien says – that the tracking system is faulty, how does he conclude that the system is creating false positives and is not underreporting the errors?  The common thread is clear.  Prince George’s and other local hospitals are failing, either at tracking untoward events or at patient care and likely injuring their patients in the process.

The truly frightening aspect is that there are an untold number of patients that were irreparably harmed by these complications.  At first blush, the State’s attempt is laudable, clearly designed to hit the hospitals in their wallets for its misgivings.  The penalties notwithstanding, the State’s initiative offers no mechanism to compensate the victims of these hospital complications.  Every indication is that the injured patients and their advocates are left to pursue alternative avenues to obtain compensation for these so-called “complications.”

 

Week in Review: If you missed this past week’s blogs – catch up!

Sunday, April 10th, 2011

This past week was a busy one for our bloggers. It was also a very busy week in our law practice. Over the last two months, we have also had two new lawyers join us – Sarah Keogh and Jason Penn. Sarah has contributed a number of posts already. Jason , who just started this past Monday, will soon be sharing his contributions, thoughts and comments with you as well. We’re very happy to have both of them. I’m sure you join us in wishing them a very warm welcome.

Last week our writers covered a number of topics related to health, medicine, child safety, medical technology and patient safety. We started the week off with a piece by Brian Nash on some key facts women need to be aware of when having an epidural for labor, delivery and post-partum pain relief.

Epidurals

There can be no doubt that thousands of epidurals are administered to women every day throughout this country. This form of analgesia (pain relief) has become probably the most popular form of anesthetic management and apparently is generally believed to be essentially risk free. As this week’s piece, Having an epidural when you have your baby? 3 questions to ask the doctor, reports, some literature gives the figure of complications from epidurals as high as 23% - ranging in severity from minor inconveniences, to life-long major disabilities and even death.

This particular piece was written as a result of several cases in which we have been involved when women, who had undergone an epidural, became essentially paralyzed from the waist down. We raise some questions for women to ask the doctor and suggest they just might want to ask those questions before they find themselves in the process of labor or when they are going through the recovery phase of having given birth to their baby. We believe it’s an important piece for women – and frankly for all – to read so that they have a much better idea of what they should expect with an epidural and what the risks and benefits are of this wonderful yet potentially life-altering anesthetic technique.

Shaken-Baby-Syndrome

On Wednesday, Jon Stefanuca again brought to the public’s attention a problem that is probably as old as childbirth. Everyone who has had the experience of taking care of a child – particularly a baby – knows that along with the joy of parenting comes the physical and emotional toll on parents and care-givers. The human condition makes us all susceptible to being less than completely tolerant, forgiving and gentle with little ones when we are under stress, frustrated or just plain exhausted. The response to the persistent crying can simply not be “a good shake.”

Medicine and science (and unfortunately the courtroom) have given a name to a syndrome of injury babies can suffer when that “just a good shake” approach is used. While a parent or care-giver may think it unimaginable to strike a child, they may not realize just now much harm they can do with “just a good shake.” Jon brings this information and some expert tips and tricks on how to deal with these difficult times parents and care-givers face in their everyday lives in his piece Shaken Baby Syndrome – What we all should know to prevent child abuse.

Makena: New Anti-Prematurity Drug

Thursday, Sarah Keogh reported on a relatively new drug called Makena, which has been found to help pregnant women, who have previously had a premature infant. I say “relatively” since according to Sarah’s piece, a compounding pharmacy could and was making this medication prior to the FDA giving K-V Pharmaceutical Company the exclusive rights to manufacture this drug for a period of 7 years.

Read Sarah’s piece, Makena: Drug to fight prematurity leads to major firestorm, and see what the controversy is all about. How could people possible be upset with a drug that can fight premature birth? Prematurity is one of the major causes of significant childbirth injuries such as cerebral palsy. Sarah’s blog makes it all too clear why people are upset and why the March of Dimes withdrew its sponsorship for Makena.

Medical Technology and Patient Safety

The week ended with Part II of my series on medical technology and whether all the new toys, bells and whistles of our modern healthcare system are truly advancing safe, efficient and effective delivery of healthcare. The week’s piece focuses on perhaps one of the largest advances in the healthcare industry – electronic medical records (EMR).

The blog, Medical Technology and Patient Safety – Part II – EMR’s (electronic medical records), brings a lawyer’s perspective to this topic. Much has already been written – and frankly will continue to be written – about EMR’s by the medical profession. Controversy has filed the pages of journals and at times probably slowed traffic on the internet (okay – maybe that’s a bit of an exaggeration) since this new marvelous technological advance was rolled-out in our medical institutions.  Those writing and fighting about it have been the end-users themselves – the medical professionals, who have to deal with the issues and flaws that have surfaced with this wonderful new technology. I thought it was about time to tell you how this plays out by another end-user – the lawyer who now deals with EMR’s. This piece is also intended as the foundation for what we as lawyer have seen play-out in terms of patient safety and health as a result of EMR implementation.

Sneak Peak of the Week Ahead

I anticipate that next week we’ll be seeing Jason Penn with his first blog on a recent report about numerous safety violations by hospitals in our practice jurisdictions – Maryland and Washington, D.C. Mike Sanders will be bringing to our readers aN old but back-in-the-news report on super infections, which still seem to be – unfortunately – thriving in our nation’s hospitals. We’ll start off this coming week with a piece by Theresa Neumann, our highly acclaimed in-house physician’s assistant expert, on spinal stroke. We all know about strokes that can damage the brain. Theresa will be sharing her insights on an equally devastating stroke of the spinal cord. I also suspect – shhh – that we’ll be reading more from Sarah Keogh this coming week. If the practice of law doesn’t get too much in the way, I am also hoping to share with you some real life examples – from a lawyer’s perspective – of just how EMR’s may not be advancing the causes of patient safety and health.

As with all our blogs, we sincerely invite you to not only read our thoughts and comments but to also share yours with us and our readers. Our latest stats show that around 10,000 pages are viewed by our readers and visitors every month! We sincerely thank all of you, who have taken the time out of your busy lives to read our offerings in The Eye Opener – Views and Opinions from the Nash Community. We invite you to share our posts with your friends and colleagues. Don’t forget to sign-up for easy delivery to your email inbox. Last – but certainly not least – come join our social media communities on Facebook and Twitter.

The Week in Review: did you miss last week’s posts on health, safety, medicine, law and healthcare?

Sunday, April 3rd, 2011

Last week we launched the first in a series called The Week in Review. We hope you enjoy this project as a way to catch-up on what  you may have missed in the world of health, medicine, patient safety, law and healthcare. Now for our second installment.

 

Yesterday is history. Tomorrow is a mystery. And today? Today is a gift. That’s why we call it the present.”

Inspirational  Quote from Babatunde Olatunji


 

We started the week with Part I in a series of posts intending to explore the issue of whether the ever-growing and expanding advances in medical technology are really accomplishing their goal – or what should be their goal: more efficient, effective and safe delivery of medical care.

The author, Brian Nash, poses the question, “What has technology done to improve healthcare?” Answering in part his own question, he states:

The answer, in short, is – some amazing things and some not so amazing things have taken place in terms of technological advances in healthcare. Unfortunately, as we will explore in this series, some of these technological advances have led to some catastrophic results for patients. One need look no further than how the medical institutions rushed to implement the newest, shiniest and “best” radiology machines and through their haste left in their wake scores of maimed and dead patients.

Read more – Medical Technology and Patient Safety: EMR’s, COW’s, iPads, etc – are they really doing the job?

 

Wednesday’s post by Sarah Keogh explored an often discussed but apparently not always heeded message about car seat safety. Sarah offers some “tips” and suggestions on how to implement simple safety steps to decrease the likelihood of injuries to children while in our cars. She reported -

A recent article on healthychildren.org says that deaths in motor vehicle crashes are still the leading cause of death for young children.

Don’t let this message go unheeded. These are not Sarah’s “tips and tricks” but those of experts in the field of child safety.

Read Sarah’s piece – 4 Tips for Car Seat Safety.

 

The end of last week brought an “interesting” piece by Mike Sanders, also a lawyer with our firm, concerning a so-called study suggesting a possible link between religious activity and obesity. This wasn’t – Mike is quick to point out – a “theory” of his. This was a posting he saw and just couldn’t stop himself from writing about.

While I am usually reluctant to belittle medical research, this study really has me scratching my head and asking, “Who cares?” Before anyone decides to skip church this weekend, let’s look at the details of the study.

Makes one wonder what it takes in today’s world of instant news, internet publishing and blog posting (hmmm), to “get published” as a study.

Read Mike’s piece entitled Can Religion Make You Fat?

The Week Ahead

This coming week will have among its postings Part II in the series about Medical Technology and whether it is doing its job of advancing the safe delivery of healthcare to our population. We’ll start with a topic that is near and dear to all in the healthcare industry – EMR’s – better known as Electronic Medical Records. Sounds like a good idea – right? Since we live in a world of computers, radio buttons and drop down boxes and way too many of us in the field of medical malpractice litigation have made too many visits to the eye doctor from having to reading hand-written medical charts – why wouldn’t this be the next best thing to sliced bread? Well – read Part II coming this week.

We also plan on posting some information and analysis of a medical/anesthesia procedure – the epidural – that thousands of women have every day of every week throughout this country and the world. Well, are they really as safe as some would have you believe? Stay tuned and read our upcoming post.

There are likely to be even more goodies on health, law, patient safety and healthcare in next week’s The Eye Opener from Nash & Associates.