Archive for the ‘Radiation Safety’ Category

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?

Medical Technology and Patient Safety: EMR’s, COW’s, iPads, etc. – are they really doing the job? Blog Series – Part I

Monday, March 28th, 2011

Medical Technology - source: Siemens.com

This is the first installment of a series of posts on issues relating to new advances in medical technology and how they may affect patient health and safety – not always for the good. Unless you live in a cave or just don’t care, you must have noticed news reports about how the medical industry is awash in the creation and implementation of new technologies. Presumably these new medical tech toys and gadgets are intended to advance the timely, enhanced, cost-effective delivery of healthcare with the end point being improved patient care and patient safety. The question is – do they always do that or can they, in fact, be tools the lead to patient injuries and – at times -even death?

I recently came across a posting by Dr. William L. Roper, MPH, CEO of the University of North Carolina Health Care System, which was in essence a transcript of a speech he gave at the Agency for Healthcare Research and Quality (AHRQ) in Washington, D.C. on March 23, 2011. Among his other vast accomplishments, in the spring of 1986, he was nominated by President Reagan and confirmed by the Senate for the position of administrator of the federal Health Care Financing Administration, with responsibility for the Medicare and Medicaid programs nationally. For the previous three years, he served on the White House domestic policy staff.

I bring Dr. Roper’s recent remarks to your attention since they are the inspiration for this series of blogs. While Dr. Roper’s address did not specifically address topics such as EMR’s, COW’s (still wondering how a cow fits into this topic? Stay tuned!), and the like, the following selected excerpts are the seeds of thought for the present series:

I have the job of leading an academic medical enterprise, and am challenged by the task of putting lofty ideas into practice at the local level. I remain very committed to the effort, but we are daily challenged to put the best ideas into practice.

The Institute of Medicine, under Sam Their’s and then Ken Shine’s leadership, played a very important role across the decade of the 1990s, defining “quality” in health care, and pointing to problems in quality and patient safety. Bill Richardson led a multi-year IOM initiative that included the groundbreaking report, To Err is Human in 2000, and then Crossing the Quality Chasm in 2001.

These reports were a clarion call for action – especially making the point that a systems approach was required to deal effectively with these issues.

While Dr. Roper’s speech was, in large part, an historical analysis of progress in the Medicare healthcare delivery system, it is also a well-versed commentary on the so-called advances in medicine for patient care and safety. Why else have so many toiled for so long in trying to find system-failures and methodologies for eradicating those failures and thereby improving the delivery of safe, efficient and effective healthcare?

Dr. Roper and so many other dedicated healthcare professionals are faced daily with the same issue – “…challenged by the task of putting lofty ideas into practice at the local level . . . [W]e are daily challenged to put the best ideas into practice.” Put another way – at least for me – taking public healthcare policy and practices and making a better widget.

As these lofty concepts were debated, published and analyzed, technology streaked along with its new bells and whistles at what some might call an amazing – almost mystifying – pace. Did you really envision yourself 25 years ago sitting with your iPhone or iPad and scouring the world’s news, chatting with your friends and followers on the other side of the planet, watching the latest streaming video of March Madness or sharing every random thought you have on Twitter or Facebook?

What has technology done to improve healthcare?

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. We reported on this investigation by NY Times reporter, Walt Bogdanich  in Eye Opener, over a year ago.

Just over the course of the last year or so, our firm has been involved in case after case in which this issue of medical technology and patient care/safety keeps rearing its ugly and devastating head. We will share with you (leaving identifying information obscured as we are required to do) tales of just how medical technology can impact – positively and (unfortunately) negatively patient health and safety. We’ll analyze and discuss our views on just how well medical technology and its implementation (more the latter) have, in our view, negatively impacted – all too often – patient health and safety. We invite you to follow along as we consider the good, the bad and the ugly of medical technology such as EMR’s, COW’s, iPads and the like. Please join us and share your comments along the way.

Some related posts to get you started:

The Radiation Boom – Radiation Offers New Cures and Ways to Do Harm

FDA Unveils Initiative To Reduce Unnecessary Radiation Exposure from Medical Imaging

At Hearing on Radiation, Calls for Better Oversight

Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging

The Story of How a New York Times Reporter – Walt Bogdanich – Has Made a Real Difference in Medical Device Radiation Safety

CT Scans – Are You Being Properly Protected Against Radiation?

Thursday, December 2nd, 2010

According to new research presented at the annual meeting of the Radiological Society of North America, breast shields should be used for men and women undergoing CT scans of the chest/lungs. According to Terry Healey, M.D., Director of thoracic radiation at Alpert Medical School of Brown University, the breast shield is capable of reducing the level of radiation by about 30%.  This is significant considering that radiation can cause or contribute to the development of various malignancies (e.g. breast cancer, lung cancer, esophageal cancer).

Although some physicians argue that the use of breast shields may impact the quality of the CT scan (i.e., by producing artifacts such as streaks or lines making the interpretation of the study more difficult), this new research suggests that the use of breast shields does not impact the diagnostic quality of the CT scan. A breast shield is nothing more than a thin piece of heavy metal placed in front of the chest during the CT scan procedure.

Researchers studied 50 patients, who needed CT scans of the chest. Most of the patients were undergoing the study to rule-out lung cancer.  For some patient the shield was placed directly on the chest. For other patients, the shield was slightly elevated from the chest surface. Overall, some artifact was present in about 2/3 of the cases. However, in the opinion of the researchers, there were no instances where the artifact interfered with the diagnostic quality of the radiographic study.

According to Judy Yee, M.D., vice chair of radiology at the University of California: ”[T]here’s no good reason not to use breast shields. The cost is relatively low and the benefit large.”

Perhaps a larger patient population is needed for the results of this research to be more widely accepted by the radiology community. We’d appreciate anyone who has experience in this field to share their thoughts on this topic. Do such shields cause artifact that makes the study less accurate and potentially dangerous to a patient? Does the accuracy of the scan, when a shield is used, depend on which type of scanner is used or which generation of scanner is being used? Are there other techniques that can be used to protect a patient yet not run the risk of artifact “mis-read”? We’re not physicians or radiology technicians, so we welcome any insights those who are might have on this topic.

If you are concerned about excessive radiation and need to undergo a chest CT, ask your radiologist if a protective shield can be used during your CT scan. Discuss the issue and – as we always stress – take charge of your own medical care. Be an informed patient and be responsible for your own health and safety. Know what the issues, risks and benefits are and discuss it with your doctor. Then – and only then – make an informed decision.

Image from emedicine.medscape.com

Hospitals Fined Heavily for Unsafe Practices – medical malpractice pure and simple!

Tuesday, November 9th, 2010

Well this headline got my immediate attention!

HOSPITAL FINED $300,000 FOR LEAVING A DRILL BIT IN PATIENT’S HEAD.  Rhode Island Hospital (RIH) was fined by the state’s Department of Health with the largest penalty in state history and only the 3rd posed against a hospital for surgical errors.

How does such a mistake happen? I went to the article and then saw similar articles over the last year.

CALIFORNIA HOSPITALS FINED FOR ENDANGERING PATIENT SAFETY

TEMPLE TO PAY (the US Government) $130,000 TO SETTLE DRUG DIVERSION CLAIMS

BOTCHED RADIATION TREATMENTS LEAD TO FINE FOR VA

Yes, states are fining hospitals, the US government is fining hospitals, and the US government is even fining government hospitals for unsafe practices. State, regional and national news publications are breaking the stories and making the public aware of their hospitals’ most costly mistakes.  Over the last two decades, more and more states are requiring hospitals to report serious errors and fining them for failing to do so. One way or the other, hospitals pay for serious mistakes and suffer media scrutiny at the same time.

The Rhode Island Director of Health reported “a troubling pattern” of patient safety procedural violations at RIH.  On October 15th of this year, a surgical instrument was found in the abdomen of a patient who had undergone surgery three months before. This followed an August incident when a quarter inch drill bit broke off in a patient undergoing brain surgery. While aware the bit was missing, no one in the operating suite investigated where it went. The next day an MRI identified the bit in the patient’s brain. This error placed the patient at serious risk of harm during the MRI. Magnetic forces during the MRI could have moved the metal drill bit causing significant brain injury.

Clinical standards of care require all surgical instruments to be counted at the beginning and end of a procedure. If the count is incorrect, xrays are immediately taken. If found in the patient, the instrument is removed before the conclusion of the procedure. This healthcare industry-wide patient safety procedure has been in place for well over 30 years. The simpe, straightforward procedure was not undertaken according to Rhode Island news reports. In addition, the state found anesthesiologists at RIH don’t wear masks while in the operating room, and no actions had been taken to correct the behavior.

The Director of Health also reported in 2009, RIH was fined $150,000 and ordered to hire a consultant to improve operating suite procedures; shut down surgeries for 1 day to conduct mandatory training; and install audio/video monitoring devices to ensure compliance. This all happened when a surgeon operated on the wrong finger which was the 5th time a wrong body part had been operated on in 3 years at RIH.  Things have not improved in 2010. The fines are getting heftier and the Centers for Medicare & Medicaid Services (CMS)  as well as state professional licensing boards are now involved. Federal government intervention has only happened one other time in Rhode Island’s healthcare history.

Rhode Island is not alone. As the headlines above show, California, after enacting a new state law in 2007, reports that over $4.8 million in healthcare administrative penalties have been issued with $2.9 million collected to date. California news stories began breaking last January (2010) when thirteen hospitals were fined $50,000 each and another was fined $25,000 four times. In April, seven more hospitals were fined. In May, nine more hospitals $550,000 in penalties imposed.

The deputy director for public health, Kathleen Billingsley, told the press that Californians have a right to receive the minimum level of required state standards. Out of 146 penalties, hospitals were appealing 37 in an April news report. Notable infractions resulting in fines included:

  • Man hospitalized with a heart attack died after his cardiac monitor had been disconnected.
  • Woman misdiagnosed with an ectopic pregnancy was given chemotherapy drugs. She was not pregnant.
  • Two ER nurses without documented clinical competencies or life support training failed to record vital signs in a 5 month old with a temperature of 105.4.
  • An operative sponge was left in a patient and discovered a year later. Three operations were required to eventually remove the sponge.
  • A wrong knee was operated on.
  • Contrast material for radiology was given to a patient with a known iodine allergy resulting in death.
  • An oxygen tank became empty during a simple ultrasound procedure resulting in the patient’s death. The patient had waited in radiology over 60 minutes for the procedure allowing the tank to run dry.
  • A patient aspirated a laryngoscope plastic blade extender during intubation for an outpatient surgery. It was not discovered until the patient called post operatively complaining of coughing up plastic.

In March, the Department of Veteran Affairs, which oversees the Philadelphia Veterans Affairs Medical Center was fined $227,500 by the Nuclear Regulatory Commission. This was the second largest fine against a medical facility. Between 2002 and 2008, Iodine 125 seeds were placed incorrectly in 97 out of 116 prostate cancer patients. There were inconsistent doses, unintended organs and tissues radiated leading to a myriad of complications for the victims including excessive radiation. Many of the incorrect procedures initially went unreported.

While I applaud these fines and would like to see stronger sanctions, several questions came to mind after reading these reports. Are states and the federal government merely cashing-in and paying-down healthcare deficits, or putting this revenue to good use such as improving patient safety? How much of the revenue is being consumed in hospital appeal proceedings? Is this an effective incentive for hospitals to change or merely perceived by them as a cost of doing business in today’s high paced and burdened healthcare system?

What do you think?

The Story of How a NY Times Reporter – Walt Bogdanich – Has Made a Real Difference in Medical Device Radiation Safety

Thursday, June 10th, 2010

No doubt we all have our opinions about the news media. Such opinions are not always positive. Maybe it’s the proliferation of talking heads, 24-hour news, clips of news reporters shoving microphones in the face of someone who has just lost a loved one or camped outside the home of some person so that every breath the target takes is reported on ad nauseam. Then there are those who truly seem to make a difference. An article in today’s New York Times brought one such ‘difference maker’ to mind.

Over the course of the last several months, an investigative reporter for the Times, Walt Bogdanich, wrote a series of chilling and revealing articles on the horrors of radiation medical devices, which when used improperly by unskilled or careless individuals, had caused serious, life-altering (and even life-ending) injuries to patients.

Bogdanich wrote a series called “The Radiation Boom,” which was the subject of an article posted here on February 2, 2010. On January 26, 2010, this reporter’s article entitled “As Technology Surges, Radiation Safeguards Lag” brought to light chilling tales of multiple victims of misused radiation medical devices.  Over-radiation by medical personnel inadequately trained in the use of new and more powerful radiation devices such as CT machines seemed to be a common denominator in these horrible clinical vignettes. Three days before “The Radiation Boom” article, on January 23, 2010, Bogdanich’s piece entitled “Radiation Offers New Cures, and Ways to Do Harm” reported on the harrowing tale of Scott Jerome-Parks:

As Scott Jerome-Parks lay dying, he clung to this wish: that his fatal radiation overdose — which left him deaf, struggling to see, unable to swallow, burned, with his teeth falling out, with ulcers in his mouth and throat, nauseated, in severe pain and finally unable to breathe — be studied and talked about publicly so that others might not have to live his nightmare.

Another outstanding health reporter, Liz Szabo of USA Today, picked-up on Bogdanich’s storyline, and reported in an article dated January 31, 2010, that NIH was implementing procedures for its doctors to record just how much radiation was being received by its patients – to avoid over-radiation exposures. On February 10th, we posted news of action by the FDA taken the day before in which the agency unveiled an initiative to reduce unnecessary radiation exposure from medical imaging. The ‘opening credit’ – so to speak – for this late awakening by the FDA was duly given to Walt Bogdanich. Our featured post of March 1, 2010 next reported on Capitol Hill hearings of the prior week involving industry leaders seeking key answers to what needed to be done to correct this situation and set guidelines for the proper use of these medical devices. On April 27th,  we once again reported on the new FDA initiative to reduce unnecessary radiation exposure from medical imaging.

Who is responsible for bringing about this public and governmental awareness of radiation-related injuries due to ignorance or malfeasance of medical personnel? There can only be one conclusion – Walt Bogdanich.

Well the story is not quite over. In today’s New York Times, he is at it once again. In the Times Health section, Bogdanich reports – in an article entitled “Safety Features Planned for Radiation Machines” -

Manufacturers of radiation therapy equipment said at a patient-safety conference here Wednesday that within the next two years their new equipment and the software that runs it would include fail-safe features to help reduce harmful radiation overdoses and other mistakes.

Having followed this series of reports and the relatively rapid-response actions taken by governmental agencies,medical institutions and private industry since its inception, I have been awed by how one man, Walt Bogdanich, has brought about not only an awareness but real change in our society and the medical industry. While we all hope to make a difference in the lives of others while we walk this earth, it is inspiring and motivational to witness a real-life “difference maker” in action.