#MeToo and the Medical Profession began open discussion only recently. Physician authors Holroyd-Laduc and Strauss write: “In the era of #MeToo, it is time for physicians to acknowledge that the medical profession is not immune to bullying, harassment and discrimination, and act to abolish these behaviours.” They further ask: “…why, with the MeToo movement, has there been no complaint against a prominent male physician?” Published in the Canadian Medical Association Journal (CMAJ) August 2018.
The Patient Safety chartbook is part of the National Healthcare Quality and Disparities Report. It shows the progress made on lowering infections, hip or knee replacement adverse events, adverse drug events, cardiac bypass readmissions, home health care improvement, frequency of safety issues in medical offices, and patient safety culture. Rates shown to 2017 (in some cases, data only to 2016; nursing home and pharmacy culture surveys data are from 2018, reported in 2019). Published October 2019 by AHRQ.
Healthgrades 2020 awards for patient safety excellence lists top 10% (456) hospitals. These hospitals are distinguished for their Medicare patient safety, using 2016 to 2018 data. Hospitals were evaluated on 14 types of preventable patient safety incidents, such as leaving foreign objects behind during surgery, pressure ulcers [bedsores], accidental cuts during medical care; deep blood clots, collapsed lung pneumothorax, postoperative hip fracture, bloodstream infection, deaths after surgical complications, and postop sepsis. Annual study released June 2020 by Healthgrades
Just how good is hospital care in the US, compared to other similar countries? The Health System Tracker by Peterson-KFF (Kaiser Family Foundation) provides trends among countries through 2016. Topics include mortality rates, treatment outcomes, access, maternal deaths, hospitalization for chronic illnesses, number of C-sections, patient safety such as post-op complications for hip and knee replacements, post-operative sepsis after abdominal surgery; and medication and lab errors. With a few exceptions, the United States does not fare as well as comparable countries. Post-op sepsis after abdominal surgery, and 30-day mortality for heart attacks and strokes are lower in the U.S. than in comparable countries. Read the full report published July 2020.
MedWatch is FDA’s (Food and Drug Administration) site for consumers to report serious adverse reactions to medications, product quality and medical device problems
National Quality Forum’s (NQF) consensus on 34 patient safety practices for hospitals are summarized in this public document. Includes practices related to organizational culture; hand hygiene and preventing infection; information documentation, labeling, and communication; caregiver practices; discharge and medication reconciliation systems; more. Finalized 2010. Table of contents shows the 34 practices presented in the 400+ page report.
The NQF list of Serious Reportable Events is sometimes called the list of Never Events. This report identifies 29 serious reportable events (SREs) considered preventable. Examples: wrong surgery; deaths or serious injury associated with medication error, or in a low-risk pregnancy, or due to a fall, or from failure to follow up on test results, or associated with certain MRI incidents; Stage 3 or 4 pressure ulcers. Applies to hospitals, clinics, nursing homes and ambulatory surgery centers. Updated edition; published by National Quality Forum (NQF)
Many resources can be found at AHRQ’s Patient Safety Network website. In the redesigned site, you may have to dig to find what you’re looking for, but it is worth the effort to try. One of our favorite pages is the All Topics page for adverse events and other safety problems, linked here. There are a number of case studies and many journal articles. Includes studies and reports from the National Health Service of the United Kingdom. The Agency for Healthcare Research and Quality is a federal agency.
“When Things Go Wrong: Responding to Adverse Events ” was prepared by the Harvard teaching hospitals. It explains how to communicate with patients about serious medical errors and adverse events. Includes elements of a hospital incident policy, sample script for communicating with patients, supporting the staff, support to families; and extensive bibliography. Published by the Massachusetts Coalition for the Prevention of Medical Errors (macoalition.org), 42 pages, March 2006. Classic publication
Data from the National Practitioner Data Bank show median malpractice payment amount in 2012 for an anesthesia related case was $240,000; for an IV or blood products related case, it was $169,000. Data are mixed up in Tables 25 and 26. Delay between incident and payment was typically 4 to 7 years. NPDB Report from 2012 is 78 pages, pub. Feb. 2014 (most recent available). Also at this site is a count of medical malpractice reports by type of practitioner (e.g. doctor vs dentist vs podiatrist) and by state current to 2019. See Data Analysis Tools.
Find the definition of a sentinel event. The Joint Commission (which accredits healthcare organizations, formerly JCAHO) defines Sentinel Events for hospitals, ambulatory clinics, surgery centers, nursing homes, home care, behavioral health facilities and other health care settings. Sentinel events reach patients and result in Death, Permanent harm, or Severe temporary harm and intervention required to sustain life. They require immediate investigation. Updated 2020.
Short summaries and pdf action guides for 9 patient safety problems: Look-alike, sound-alike medication names; Patient identification; Communication during patient hand-overs; Performing correct procedure at correct body site; Concentrated Electrolyte solutions; Medication accuracy at transitions in care; Catheter and tubing mis-connections; Single use of injection devices, and Hand Hygiene to prevent health care-associated infections. From the World Health Organization (WHO) and Joint Commission / International, 2007