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!