How much patient safety is too much?

Recently I read an interesting article about patient safety. The author discussed the growing trend of involving patient's in their care, for example, by asking patients to 'mark' the site of surgery. Is it too much, he asks? Are these patient safety measures being implemented to protect providers against malpractice suits? The author notes,

True, serious medical mistakes do happen. I heard a rumor that a New York doctor accidentally left a barbecue grill inside a patient. Another doctor transplanted a viable liver into the wrong patient's head. Malpractice lawsuits have forced doctors to take unusual measures. Before my wife was wheeled into the operating room at the surgical center, she was given a Magic Marker and told to mark the location of her chemo port with an X. This seemed rather pointless given that the port was clearly poking out of her chest ... On another gurney, a patient waiting to have his knee scoped was asked to write "yes" on the appropriate knee... Maybe this sort of patient participation cuts down on surgical mistakes. Maybe it just reduces doctors' liability. I asked the medical staff. They said it was just one more way of making sure everything went according to plan... Malpractice litigation must be worse than I thought. Do expectant mothers have to draw these helpful diagrams: "Baby comes out here" with an arrow?

The patient safety measure the author is referring to is of course, Universal Protocol, which ensures that marking the procedure site allows staff to identify (without ambiguity) the intended site for the procedure. I'm not sure how many hospitals actually require the patient do the marking, but I am aware of having patients involved in the process. Many of these patient safety measures we hear about, including Universal Protocol, have come about because of cases where hospital staff have made mistakes and done surgery on the wrong limb etc.

So has patient safety gone too far? I don't think so. If we weigh the burden of implementing these patient safety measures against the number of lives that have been saved and the numbers of medical errors which have been prevented - I tend to think we're on the right track. It seems that the direction patient safety is heading these days, we'll be seeing a lot more patient involvement in their care. Involving patients in this manner is not taking the duty away from healthcare providers, but in fact, it's empowering patient's to be partners in their care... and that can't be a bad thing, right?

Collective Intelligence: Google Can Do It. What Can Health Care Do?

Wikipedia, Youtube, Facebook, blogs...how many times a day do you visit these pages? Don't know something? Wiki it. Want to watch something? Youtube it. Think you know someone? Facebook him. Want to voice an opinion? Blog it. The internet has become a very powerful source of information and better yet, it's a shared source of information that exhibits boundarilessness and speed.

But that's not all. Recent technologies and initiatives have harnessed the actual use of the internet as a form of collective intelligence, a form of group intelligence that results from the collaboration or competition of individuals. Like the cliche, "There is no "I" in Team," collective intelligence values in the input of all members for the good of the whole (information provided by Wikipedia.org).

Several of the websites mentioned above take advantage of this very concept. Wikipedia is an open source collaborative that allows anyone and everyone to contribute encyclopedia entries on just about everything. Fact checking and reliability is also in the hands of anyone and everyone around the world. While the title Youtube may suggest vanity in creating your own 15 minutes of fame, it is also a shared pool that is accessible to everyone. Perhaps Wetube is a more accurate name.

Collective intelligence has three main facets: cooperation, coordination, and cognition. Wikipedia, Youtube, and Facebook have thrived on cooperation and coordination by creating virtual communities around shared interests and widely spreading information. Only recently has the cognition facet of collective intelligence begun to take form.

The cognition facet of collective intelligence allows for the study of behaviors and capturing the force of those behaviors. This facet transforms the internet beyond a shared pool of knowledge into a powerful tool for social change. Let's consider some examples.

In September, Science published an article about reCAPTCHA, a free CAPTCHA service that helps to digitize books. A CAPTCHA is a Completely Automated Public Turing test to tell Computers and Humans Apart. We have actually all come across CAPTCHAs- they are used by several websites to verify that the entity filling out a web form is a person and not a machine. Does retyping a distorted jumble of letters and numbers sound familiar?



Consider this. Suppose it take 10 seconds for each person to retype the jumbled combination, and that there are millions of people on the internet at any given time of the day. In this context, the minuscule 10 seconds of "wasted time", in aggregate becomes an enormous untapped pool of productive man hours.

Now, consider this. The Internet Archive and Google Books Project are currently digitizing books with a crew of expert transcribers and sophisticated computers. Computers are able to do most of the work, but when it comes to difficult to read yellowed distorted texts, computers are only able to decipher about 20% of the words accurately. Human transcribers are over 99% accurate, but hiring them can be expensive.

Combining the large pool of productive man hours and the great need for humans to perform what machines can't, you get reCAPTCHA. reCAPTCHA is being used by 40,000 websites and demonstrates that old printed material can be transcribed word by word by having people solve CAPTCHAs throughout the web with accuracy over 99%. More importantly, Luis von Ahn and his reCAPTCHA technology are capitalizing on internet behaviors to help digitize books and make human knowledge more accessible. Thank you collective intelligence.

Can the health care industry take advantage of collective intelligence too? Google has taken a stab at it. Google has become the go-to gateway of information. And as we use it to research information for our specific purposes, Google can use our "Google it" attitude to collect information about us! In a unique pairing of the internet and public health, Google has been able to track the spread of influenza 10 days faster than the Centers for Disease Control and Prevention (CDC) by tracking the number of searches for words like "flu", "flu symptoms", and "influenza".

Source: New York Times

Since the data collected by the CDC is dependent on information collected by patients interacting with health care through doctor visits and lab tests, the CDC's ability to follow flu outbreaks is slower. More information about the flu trend that Google.org, Google's philanthropic division, is tracking can be found at www.google.org/flutrends/.

Google has helped to prove that health care can benefit from the power of collective intelligence. What else is possible? Please share your thoughts!

"I Watch the Line"

Two weeks ago, the IHI Open School talked to Dr. Peter Pronovost about checklists and how checklists could help in standardizing the practice of medicine and reduce medical errors in the IHI Open School On Call Series.

One such checklist or bundle at the IHI 5 Million Lives Campaign is to prevent central line infections. As Dr. Pronovost mentioned on the call, central lines are used to feed patients drugs, nutrients, and other important fluids. Because this catheter is a foreign object placed in the body, it is prone to infection, which is highly dangerous for the patient. Years ago, central line infections were thought to be an inevitable medical hazard. But, after careful study, a central line bundle was created to reduce and eliminate central line infections. This bundle includes things as simple as hand washing and maintaining a sterile environment. Click here to download Dr. Pronovost's Central Line Infection Checklist (the checklist is also available at www.ihi.org).

Several hospitals have quickly adopted such checklists and have achieved remarkable results. Below is a Youtube video celebrating the Johns Hopkins and Adventist Health System central line research initiative. This video just goes to show that checklists are not only useful, but can be fun too! Enjoy!

Thank you Frank Federico for sharing this with us!

Yes We Can: Health Care's New Motto?

After much anticipation, we've elected a new President! Over the last 21 months many of us have followed Obama and have embraced a new culture: change.

Enacting change won't be easy for anyone. As Obama said in his acceptance speech last night:

...For even as we celebrate tonight, we know the challenges that tomorrow will bring are the greatest of our lifetime - two wars, a planet in peril, the worst financial crisis in a century. Even as we stand here tonight, we know there are brave Americans waking up in the deserts of Iraq and the mountains of Afghanistan to risk their lives for us. There are mothers and fathers who will lie awake after their children fall asleep and wonder how they'll make the mortgage, or pay their doctor's bills, or save enough for college. There is new energy to harness and new jobs to be created; new schools to build and threats to meet and alliances to repair.

The road ahead will be long. Our climb will be steep. We may not get there in one year or even one term, but America - I have never been more hopeful than I am tonight that we will get there. I promise you - we as a people will get there...

...This election had many firsts and many stories that will be told for generations. But one that's on my mind tonight is about a woman who cast her ballot in Atlanta. She's a lot like the millions of others who stood in line to make their voice heard in this election except for one thing - Ann Nixon Cooper is 106 years old.

She was born just a generation past slavery; a time when there were no cars on the road or planes in the sky; when someone like her couldn't vote for two reasons - because she was a woman and because of the color of her skin.

And tonight, I think about all that she's seen throughout her century in America - the heartache and the hope; the struggle and the progress; the times we were told that we can't, and the people who pressed on with that American creed: Yes we can.

At a time when women's voices were silenced and their hopes dismissed, she lived to see them stand up and speak out and reach for the ballot. Yes we can.

When there was despair in the dust bowl and depression across the land, she saw a nation conquer fear itself with a New Deal, new jobs and a new sense of common purpose. Yes we can.

When the bombs fell on our harbor and tyranny threatened the world, she was there to witness a generation rise to greatness and a democracy was saved. Yes we can.

She was there for the buses in Montgomery, the hoses in Birmingham, a bridge in Selma, and a preacher from Atlanta who told a people that "We Shall Overcome." Yes we can.

A man touched down on the moon, a wall came down in Berlin, a world was connected by our own science and imagination. And this year, in this election, she touched her finger to a screen, and cast her vote, because after 106 years in America, through the best of times and the darkest of hours, she knows how America can change. Yes we can.

America, we have come so far. We have seen so much. But there is so much more to do. So tonight, let us ask ourselves - if our children should live to see the next century; if my daughters should be so lucky to live as long as Ann Nixon Cooper, what change will they see? What progress will we have made?

This is our chance to answer that call. This is our moment. This is our time - to put our people back to work and open doors of opportunity for our kids; to restore prosperity and promote the cause of peace; to reclaim the American Dream and reaffirm that fundamental truth - that out of many, we are one; that while we breathe, we hope, and where we are met with cynicism, and doubt, and those who tell us that we can't, we will respond with that timeless creed that sums up the spirit of a people:

Yes We Can. Thank you, God bless you, and may God Bless the United States of America.

- courtesy of Yahoo! News

So what does change have in store for us in the realm of health care? Kaiser Family Foundation's Daily Health Policy Report sums up a few opinions and editorials of what we can expect in the road ahead. We all know that health care reform is needed, what do you think those next steps towards change will be?

20th Annual National Forum

Happy Halloween!

Celebrate the holiday with this sweet opportunity!



Every year in December, IHI hosts a National Forum on quality improvement in health care and this year there is a new student track available. Click here for more information.

The student track features The National Forum Clarion Case Study Competition, hosted by the University of Minnesota and the IHI Open School for Health Professions. The Clarion Case Study Competition is an interprofessional team competition for health professions students to collaborate on creating a simple root cause analysis of a sentinel event with recommended changes. Each group will be assigned a 15 minute time slot to present their case study to a panel of interprofessional expert judges. The top three winners will receive prizes! No experience is necessary. To participate, add code CCSC into the "Add Session by Code" when registering for the Forum. If you have already registered but would like to participate, please don't hesitate to contact us!

Student Scholarships are available. Please e-mail me (eluo@ihi.org) for an application!

How a Simple Checklist Can Dramatically Reduce Medical Errors

On Call Audio Conference
How a Simple Checklist Can Dramatically Reduce Medical Errors

Monday, November 3, 2008
5:30 - 6:30 PM Eastern Time
4:30 - 5:30 PM Central Time
3:30 - 4:30 PM Mountain Time
2:30 - 3:30 PM Pacific Time


Often the simplest tool can make the biggest difference.

In 2003, ICUs in Michigan implemented a humble checklist of basic hygiene and sterilization practices. After three months, infection rates dropped from 2.7 per 1,000 patients to zero.
After 18 months, more than 1,500 lives had been saved.

Since then, checklist creator Peter Pronovost, MD, has developed several other checklists that have helped clinicians across the world dramatically reduce the medical errors that lead to hospital infections. As a result, TIME magazine named him one of the 100 most influential people of 2008 and he recently received a "genius grant” from the John D. and Catherine T. MacArthur Foundation.

Join us for a conversation with Dr. Pronovost and learn:
• What inspired him to develop the checklist
• How patients and caregivers benefit from the use of checklists
• The hurdles and surprises he encountered in implementing the first checklist
• The best way to go about getting your own improvement suggestions adopted

Join the Discussion
Advanced registration is required.
Click here to register.
Don’t forget to write down the passcode you’re assigned since you will need it to join the call.


This free call is part of a monthly audio conference series that brings experts in health care improvement together with students from medicine, nursing, dentistry, pharmacy, health care management, public health, and other allied health professions. Each hour-long call is moderated by a student, ends with a question-and-answer period, and focuses on an issue that affects you. Visit our website to download audio files or written transcripts of past On Call audio conferences.

Practice Makes Perfect: Patient-Centered Care

Patient-Centered care is one of the six aims in the Institute of Medicine (IOM) report, Crossing the Quality Chasm, and arguably the most important of the six aims. As silly as this may sound, the aim reminds everyone that patients are people too. Patients are in a vulnerable position when they seek care. They are reaching out for advice, assistance, reassurance, support, and expert knowledge. So, the least health care professionals can do is to respect their patients' preferences and work with the patients when delivering care.

After allowing 2nd year medical school student friends of mine examine my severe otitis (fluid in the ear), I now realize that achieving the patient-centered care aim is much easier said than done. As I described my ailment, I slowly felt myself transforming into a specimen with "cool pathology described in textbooks!"

I'll admit that I too was excited to be "examined." After-all, I would be in their shoes in just a few short years. But apprehension soon took over my curiosity as I was reminded that my giggling would make it difficult for them to examine me and was a sign of my noncompliance. This doctor speak quickly changed the mood. I had three of my friends, or rather doctors in the making, stick their otoscopes into my ear in succession.

Friend 1 was very hesitant. She was unable to see what was later described to me as bubbles behind my ear drum until I told her she could probably stick the otoscope farther into my ear. I appreciated her hesitancy, which I translated as a sincere concern for accidentally puncturing my ear drum.

Friend 2 was just the opposite of Friend 1. Friend 2 approached me with palpable confidence. Her eyes glowed with excitement and her hand gripped the otoscope in the same fashion an eager kid holds his spoon when given ice cream. Perhaps she was compensating for her height (something I can relate to since I stand proudly at 5'1"), but she pulled a little too hard on my ear lobe and practically jammed the otoscope into my ear. Only after seeing my pained expression did she say, "Oh, I'm sorry. Please let me know if I'm hurting you."

Friend 3 finally "got it right." Maybe it was because she benefited from watching Friend 1 and Friend 2. She approached me in warm and collected way- not overconfident but definitely in control of the situation. She told me before making any movements to let her know if she was hurting me since it was not supposed to hurt. The otoscope was inserted in a straight path rather than in the wandering multi-directional course Friend 1 and Friend 2 had used. After a few seconds of silence, she said, "Oh, I see it! It does look like a cluster of bubbles behind your ear drum."

I know all three friends will be excellent doctors. They are diligent in their studies, passionate about helping patients, and dedicated to their chosen career journey. But how do you learn exceptional bedside manner? As a patient, I am oftentimes hesitant to question a procedure because I assume that since the doctors are the experts, they know best. How do health care professionals achieve the balance between being a walking encyclopedia of health and ensuring the comfort of their patients?

On the one hand, it takes an active acknowledgment that patients are people too. And, I suppose, on the other hand, it takes practice. So, to Friends 1, 2,and 3, I'm glad to have helped in your medical training by being an example of severe otitis pathology and helping you hone your bedside manner skills. Patient-centered care takes practice to make perfect!

Click here to read an article on the Slate written by a standardized patient about her experience helping 2nd year medical students practice performing physicals. Thanks for sending me this article Emory!

My day with the IHI Open School team

I'm a 6th year student at high school in Scotland. Having a day at the IHI was great.

I started by meeting various staff members and learning a bit about the IHI Open School. They were all very nice and I was really impressed with what I heard.

Being a potential medical student, I spent my day getting a better understanding of quality improvement in healthcare and helping the Open School team by being a sort-of 'focus group' .. the group consisting of only me.

I started with reading a couple of case studies, and following the guidelines for case study questions, I made up some questions for a few of the case studies.

I then started the course in quality improvement on the IHI Open School website. I was really impressed by the course. I never knew courses like this existed and it was a great way of learning for me. After completing the first lesson I felt that I had gained a good understanding of errors and how they can happen anywhere, to anyone and ways to go about responding to these errors. Although I only got through a small section of the course, I intend on doing many more in the near future.

In the afternoon I was filmed being interviewed by Deepa. It was my first ever interview and was quite scary, but I enjoyed it. I was asked questions about what I want to do in the future and why.

I then gave my feedback from the courses and we discussed each part.

I feel that I have had a very successful day at the IHI and I have developed a good understanding of health improvement.

Thank you all the team who made my day so successful :-)

Unfortunately, a familiar story...

**NOTE: names and locations have been changed or omitted to protect the privacy of those concerned**

Just over a week ago, my friend's little brother, Sam, was hit by a car while riding his bike. The accident was very serious. Sam and four of his competitive biking friends were riding together when a car hit him from behind causing him to fly through another car's windshield. Upon arrival in the hospital, Sam was unconscious, had difficulties breathing on his own, and had deep lacerations on each of his knees. Thankfully, his internal organs were stable and he did not suffer from any fractures.

After a few very tense days in the Trauma Center, CT scans had revealed that the bleeding in Sam's brain had stopped and the brain swelling was slowing getting under control. He remained on a ventilator to regulate his breathing. While Sam was starting to look better, he ran a high fever and developed signs of pneumonia. In order to allow his body to recuperate and avoid other complications, he was given sedatives to keep him unconscious.

Sam, originally from Charlotte, is a college sophomore studying in Springfield. His family dropped everything to travel to Springfield to be there with him. Once Sam's had regained consciousness and his condition had stabilized enough to move him to the ICU, his mom and dad would read to him is favorite books, tell him about some of his favorite trips to South America and Europe, and read to him excerpts from the bible. This was to try to calm Sam as he would always wake-up very agitated and attempt to yank off all of the tubes that were connected to him. Things just had to be taken a day at a time with such severe head trauma.

Very slowly Sam was coached on how to breathe on his own. After a few more days, Sam progressed from only saying "hurt" and crying uncontrollably, to being able to answer basic questions such as, "what is your name?" and "how old are you?" Every night, Sam's parents would write an e-mail to Sam's best friend David. David would then post the e-mail onto Facebook so that all of us could keep up with Sam's progress in the hospital. Without any medical training to offer medical advice and residing far enough away that visiting was not feasible, all I could do was pray for the best and monitor Sam's progress via Facebook. Reading about Sam's positive progress allowed me to breathe a momentary sigh of relief every night.

But after a week of incremental steps of good news, Sam's parents' latest post sent me tumbling back down to the same emotional state I was in when I first found out that he had been hit by a car. The e-mail:

Another sleepless night set in last night. Sam's condition was stable yesterday. When he was awake, he was crying most of the time. The doctor does not know if he shows his true emotions or if he is just that way due to a severe shear injury. Sam was transferred to a regular room at 9 P.M. The first room that he was transported to had air conditioning problems. He then got switched to another room. Sam was sweating profusely and his heart rate went up drastically. The nurse gave him medicine. However, he became more agitated. At one point his body was stiff and he shook profusely. I was extremely upset and frustrated since clearly, the nurses were not equipped to deal with Sam's condition on this floor. He was supposed to go to the Progressive ICU but, the floor was full. Dr. Thompson decided to send him to a regular neuro floor. Sam got a very nice nurse but, she had 4 other patients to attend to. In addition, she was not allowed to administer certain kinds medicine in her unit. After both Jim and I could not get Sam to calm down and his heart rate went up to almost 150. I asked the nurse to call the doctor. When Dr. Fulton came, I expressed my concern that the unit that Sam was currently in was not quite ready to know how to handle Sam's condition. I requested him to get Sam to the Progressive ICU for better care. He was not empathetic to my plea. Since I figured that Sam is at his mercy, I insisted that he must come up with a plan to deal with Sam's situation if he does not move Sam to the Progressive ICU. He promised me that he would look at Sam's medical record and let me know what type of medicine he can give in the unit to help Sam with his medical condition. Sadly, he got called to the Emergency Room to take care of two other patients and did not have a chance to look at Sam's record right away and later ordered the nurse to give Sam Valium every 6 hours.

It has been a very frustrating and exhausting experience dealing with some of the doctors and nurses in this hospital. The sanitation conditions could be improved. I had to buy Lysol wipes and Lysol spray to try to keep Sam from getting infections. When Sam had the MRI, I asked for a copy of the report. The Medical Records Office refused to furnish it and cited that the hospital policy is to not release any records, even from doctor to doctor, until Sam was discharged. I was flabbergasted at the refusal. Regardless, I did not give up and finally they caved in. Dr. Morton, Dr. Fulton, and Dr. Lee finally came around noon today. We asked them to come up with a coherent plan to help Sam adjust to the new environment. It is very difficult to go from a lot medication to practically very little. I asked them to find a happy medium to help Sam adjust slowly. We need to work together in order to help Sam continue his progress and avoid any set backs. They agreed, so we are hoping that Sam will feel better soon. It is very ironic that we have to face two battles, one with helping Sam recover from his severe injury and the other with constantly fighting for Sam's rights of treatment. The latter has exhausted us more. Take care and God Bless.

Karen and Jim

Unfortunately, Karen and Jim's e-mail is a familiar story. Doctors and nurses are not to be blamed because they are operating in a system that requires more than every ounce of effort that they can contribute. Sam's familiar story calls for a immediate need for a cultural change in the health care industry; to one that emphasizes patient safety and the quality of care delivered.

When patients and families seek medical care, they are inviting doctors, nurses, and the medical institution into their lives. Patients and families' emotional strings are already stretched thin as they hope for a speedy and full recovery. The last thing they would ask for is to be placed in a situation where they feel that they have to fight the very system they are requesting help from.

Even though we have made considerable and commendable progress in improving the quality of health care by reducing the number of patients with hospital acquired infections, pressure ulcers, and wrong-side surgeries, our work is far from over. Sam's story and many others just like it, remind us that we still have lots to do.

No more pencils no more books…

I took 22 credits one term, survived four terms of Biostatistics, and thought I was learning the essentials of public health. So I was a little dismayed when I started my first job in a large health care organization and realized how much I still didn't know.

On day one, we enter the health care environment and are thrown into an ocean of providers from every discipline. People from different professions often think in really different ways – and that leads to awful misunderstandings and mix-ups in clinical settings.

So what can we do about it? The IHI Open School can help you form good habits early and show you how to work with people from other disciplines – before you get thrown together caring for patients in a hospital.

I wish the IHI Open School had existed four years ago, when I was an undergrad studying health policy and administration. During our orientation, they required we take the "colors" personality test. Like Myers-Briggs, the colors test identifies your personality type (creative thinker, Type A, etc).

Out of the 25 health policy and administration students, would you like to guess how many of us were categorized as "Gold" (type A)? I think it was somewhere in the neighborhood of 13. We wear suits. We keep the lights on in the hospital. We are responsible for the "bottom line." When it came to group projects, inevitably, two people had rough drafts on color-coded excel spreadsheets before the first meeting even began.

Then it was on to grad school for public health. To date, I've never met so many positive Pollyannas in my life (cue the song “Heal the World”). It was an awesome, motivational point in life, but perhaps not an accurate portrayal of the care environment.

Think about how different this is from your typical med student. Motivated? Yes. Organized? Probably, but I'm under the impression their thought process is different. From day one, medical/nursing/pharm students are inundated with data. Calculating drips and converting kilos to lbs is second nature to them. I, on the other hand, want a pen and paper to write it out, step by step.

All of us in health care may share a common goal, but we think differently – and the time to find that out isn’t at the patient’s bedside. We must learn how to work together as a multidisciplinary team, communicating effectively. It's not that nurses dislike physicians or physicians dislike pharmacists; we just don't always speak the same language.

The IHI Open School will help us overcome this obstacle. We'll bring students of all disciplines together. If your care team can't communicate effectively, you’re doing a disservice to the years of training you’ve put in.