According to a seminal 2015 report on diagnostic errors1  by the Institute of Medicine,

“It is likely that most of us will experience at least one diagnostic error in our lifetime, sometimes with devastating consequences.”

Indeed, studies on diagnostic error in the U.S. have suggested overall misdiagnosis rates from 5%2 to 15%3 and as high as 97% for certain diseases like Celiac Disease4.

Misdiagnosis results in poor patient outcomes and excessive healthcare costs. A Johns Hopkins study5 concluded that it is also the single largest cause of medical malpractice lawsuits, accounting for 35.2% of payouts and an estimated 80,000 to 160,000 potentially avoidable deaths and significant permanent injuries each year.

The misdiagnoses stem from delays or failure to treat an underlying disease or from treating diseases that are not actually present. That would make diagnostic errors the third leading cause of death6 in the U.S. after heart disease and cancer. A study published in BMJ reports that approximately half of all diagnostic errors7 with adult outpatients are potentially harmful.

Telemedicine and COVID-19 Impact

Potentially exacerbating the diagnostic error rate is the growth in telemedicine over the last decade. The use of telemedicine has increased by 50-175x8 during the COVID-19 pandemic, according to a McKinsey study.

On the one hand, telemedicine may increase accessibility, thereby enabling earlier diagnoses that can result in better patient outcomes. On the other hand, what happens when a physician cannot perform the full physical examination on a patient via phone or video chat that could be done in the clinic? Will important clues be missed when relying largely on a patient’s descriptions of her symptoms?

Not surprisingly, The Doctors Company, a leading malpractice carrier, reports9 that diagnostic error is the most common allegation10 in telemedicine-related claims against their members. The top telemedicine misdiagnoses include:

  • cancer (25%),
  • stroke (20%),
  • infection (20%)
  • orthopedic concerns (10%).

Historically, telemedicine-related claims have been a small component of claims.

But the McKinsey study reports that 76% of consumers want to use telemedicine going forward, up from 11% actual usage in 2019. And 57% of providers view telehealth more favorably than they did before COVID-19. So, we can expect telehealth to be an even more significant component of patient encounters in the future—and diagnostic error rates to potentially grow if the right precautions aren’t followed.

COVID-19 likely impacts diagnostic error rates in other ways:

  • The disease itself can express in a multitude of symptoms, complicating diagnoses.
  • Clinical staff is stretched during outbreak surges, potentially leading to cognitive fatigue.
  • Quickly introduced provider organizational processes to address the surge while promoting staff and patient safety could make clinicians more error-prone.

An Inconvenient Truth

If diagnostic errors are such a big deal, why don’t we hear more about it?

“Overall, diagnostic errors have been underappreciated and under-recognized because they’re difficult to measure and keep track of owing to the frequent gap between the time the error occurs and when it’s detected,” says Dr. David Newman-Toker, leader of the Johns Hopkins study.

“These are frequent problems that have played second fiddle to medical and surgical errors, which are evident more immediately.”

Indeed, accurate data on diagnostic error rates are exceedingly hard to come by, so no one knows for sure. Even the definition of diagnostic error has been the subject of much discussion amongst those who follow the topic. Nevertheless, physicians I’ve spoken with agree that it is much more common than the public realizes.

Reluctance to report

In addition, Newman-Toker suggests that experts have downplayed the scope of diagnostic errors because they are afraid to open a can of worms they can’t close. He says, “Progress has been made confronting other types of patient harm, but there’s probably not going to be a magic-bullet solution for diagnostic errors because they are more complex and diverse than other patient safety issues.

It should also be noted that traditionally, physicians and other clinicians have been reluctant to report their colleagues’ diagnostic errors when noticed due to a culture of mutual support.

They’ve also been reluctant to self-report mistakes in fear of malpractice liability. Similarly, hospitals and other provider organizations have an incentive to protect their reputation and finances by not drawing attention to diagnostic errors. It’s also natural to believe that while such errors may be more common than generally appreciated, the problem lies with others.

What is diagnostic error?

Diagnostic error can be thought of as a failure to accurately identify and communicate on a timely basis the cause of a patient’s health problems. Not surprisingly, effective treatment plans—from both patient outcome and cost perspectives—depend largely on accurate and timely diagnoses.

The Society to Improve Diagnosis in Medicine11 suggests that there are three subcategories of diagnostic error:

1. Wrong diagnosis

An example would be when a patient who is having a heart attack is diagnosed as having acid indigestion. The accurate diagnosis may be identified from a post-mortem study. This, of course, isn’t always done. And when it is, the data isn’t necessarily flagged and reported as a diagnostic error, making actual data hard to quantify.

2. Delayed diagnosis

The most common is cancer. If it isn’t detected early, it usually becomes much harder to treat. However, many illnesses aren’t suspected until symptoms persist or worsen.

3. Missed diagnosis

Sometimes the causes of patients’ complaints are simply not identified. Examples might include chronic headaches or fatigue or loss of appetite.

Why do we have so many diagnostic errors?

The causes of diagnostic error are many. They can be attributed to cognitive issues driven by the complexity of diagnosis and to system issues driven by the way healthcare is delivered.

With almost 70,000 diseases12 represented by ICD-10-CM diagnosis codes, but less than 200 presenting symptoms,13 it is impossible for any physician to know about every disease and its associated signs and symptoms. Even with clinical decision support tools and access to expert databases, getting to the right diagnosis requires a strong foundation in the diagnostic reasoning process. This is what many would describe as the “Sherlock Holmes part of medicine.”

It’s critical to understand why one would ask certain patient history questions, conduct certain physical exams, consider certain diseases (“differential diagnoses”), and order certain tests from thousands available to efficiently evaluate the most likely or most harmful diagnoses. Of course, one must accurately interpret those findings to get to the right diagnosis so the right treatment can be provided.

Related Content: 
Diagnostic Error: A Missed Opportunity to Improve Patient Safety?
The Why and How of Diagnostic Errors

-To err is human

To err is human, and the potential for cognitive error is significant when time and cost pressures make it difficult to be as comprehensive as one would like. A physician may resort to pattern matching. Perhaps he saw this combination of symptoms in a patient recently and quickly concludes it is, therefore the same disease. While efficient in time, the diagnosis may, in fact, not be the same.

He must therefore know when it’s critical to investigate other possibilities. Or he may have failed to ask questions, conduct physical exams or order tests that might have been pivotal in narrowing the differential diagnoses. Adding to the challenge, the patient may not have accurately described her symptoms. Any of these issues can lead to premature—and incorrect—closure.

Less experienced physicians may exclude an important hypothesis simply because the patient doesn’t exhibit all the classic symptoms. Yet patients seldom exhibit all “classic” signs and symptoms. Learning time and cost naturally limit the variety of patient encounters and presentations during apprenticeship training and residency.

-Lack of feedback

Unfortunately, providers rarely get feedback if a diagnosis was incorrect or changed. There are no standardized measures of diagnostic accuracy that are reported back to them.

Usage of the non-forensic autopsy, the gold standard in identifying diagnostic errors, has dropped dramatically since the 1950s.14 In 1970, JCAHO eliminated minimum autopsy rates as an accreditation requirement. In 1986, Medicare stopped paying for autopsies. Not surprisingly, by 2005, they were performed in less than 10% of all hospital deaths, with far lower rates at non-academic institutions, if at all.

–System infrastructure

System infrastructure and process issues also contribute to the problem. Critical diagnostic tests must be available and affordable. Data must be accurate, and results must be communicated on a timely basis. Operational, communications, or collaboration breakdowns might get in the way, especially when patients are transferred between facilities, physicians, or departments. Specialists must be available when consultations are necessary.


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As clinician shortages and value-based reimbursement put pressure on the length of time available for appointments, adequate patient-provider face time for the critical patient history and physical exam becomes increasingly difficult to obtain. Inadequacies in these areas are present in 56% and 47% of missed diagnoses,15 respectively.

While electronic medical records provide an important repository of information that makes collaboration and follow-up more effective, the data entry and other paperwork, which can take 50% of a physician’s time,16 makes it even harder to get adequate patient-provider face time.

While any one of the cognitive or systems issues can lead to diagnostic error, research17 has shown that oftentimes multiple issues come into play.

Outlook

The first step in addressing any problem is to acknowledge that the problem exists. While it has been difficult to accurately quantify the scope of our nation’s diagnostic error rate, there is growing recognition that it is a large issue that must be dealt with. Patient safety, of course, is paramount. And it is core to the Hippocratic oath.

Leading researchers on diagnostic accuracy like Dr. David Newman-Toker of Johns Hopkins, Dr. Hardeep Singh of Houston Veterans Affairs Center for Innovations in Quality, Effectiveness, and Safety, Dr. Mark Graber, former President of the Society to Improve Diagnosis in Medicine, and many others have long reported on the estimated magnitude and causes of diagnostic error. The Institute of Medicine report was an important validation of their work and has brought even greater national attention to the issue.

-Policies to support effective diagnosis

A paper on the global burden of diagnostic errors in primary care18 by Dr. Singh et al. identifies eight potential interventions to reduce such errors. These range from improving diagnostic reasoning, information technology, and access to diagnostic tests to involving patients, optimizing diagnostic strategies, developing ways to identify and learn from diagnostic errors, and providing systemic diagnostic feedback to clinicians. In addition, the authors recommend government policies that specifically support effective diagnosis at the primary care level (Fig. 1).

Graphic reduce burden diagnostic error

Figure 1: Potential interventions to reduce the global burden of diagnostic errors. IT, information technology; POCT, point-of-care testing (Graphic has (CC BY-NC 4.0) license. https://creativecommons.org/licenses/by-nc/4.0/

 

-Mitigation strategies

To reduce the risk of diagnostic error in the COVID-19 era,19 Drs. Tejal Gandhi and Hardeep Singh recommend mitigation strategies using the Safer DX framework. This framework uses technology and other systems-based approaches to reducing diagnostic error:

  • Electronic decision support systems to assist clinicians in interpreting tests
  • Technology-facilitated safety practices, including outreach to patients who have missed appointments to prevent delays in evaluation and diagnosis as well as triage protocols and follow-up systems to optimize telemedicine
  • Changes to workflow and communication to support comprehensive discussions with patients about symptoms and concerns, and physician buddy systems for clinicians working in unfamiliar areas
  • People-focused interventions such as multi-clinician “diagnostic huddles” for challenging cases, and tools for patient self-triage and awareness of when to seek medical attention
  • Provider organizational strategies to ensure a strong safety culture in which staff feel free to ask for help or express concerns, get support as needed, and are less likely to have the fatigue, stress, and anxiety that can impair cognitive function
  • State/federal policies and regulations, including guidelines on standardized diagnostic performance and outcomes metrics

Yet, a 2019 review of 26 studies20 that recommended strategies to reduce diagnostic errors revealed limited evidence on interventions being practically used. Knowing what to do may be necessary, but not sufficient, to improving diagnostic accuracy given its complex issues.

-Shift to value-based reimbursement

Perhaps the greatest catalyst for addressing diagnostic error on a broad scale will be the rapid shift in healthcare from a volume-driven fee-for-service reimbursement system to outcomes and a cost-effectiveness-driven value-based reimbursement system. With this new payment environment, diagnostic error rates will directly impact provider revenue and financial stability. 

No provider organization wants to waste money on treating the wrong disease while the real disease escalates to the point where it is much costlier to deal with, or the patient dies—both of which are bad under value-based reimbursement. And provider organizations are looking at ways to leverage more nurse practitioners and physician assistants, who may be more available and less expensive than physicians. But they also have less training.

Thus, health systems are getting serious about diagnostic accuracy. They experiment with real-time clinical decision support tools and artificial intelligence systems that prompt the clinician to consider certain diagnoses. And they make sure that they utilize advances in broadly scalable online simulation technology to evaluate their new and experienced clinical staff on diagnostic reasoning and to remediate or provide continuing education as appropriate.


References


  1. Improving Diagnosis in Health Care. The National Academies Express.  Consensus Study Report 2015  https://www.nap.edu/catalog/21794/improving-diagnosis-in-health-care
  2. Hardeep Singh,1 Ashley N D Meyer,1 Eric J Thomas2.  The frequency of diagnostic errors
    in outpatient care: estimations from three large observational studies involving US adult populations, Open Access, BMJ Quality & Safety Online First, published on 5 May 2014 as 10.1136/bmjqs-2013-002627 
  3. Mark L. Graber, MDNancy Franklin, PhDRuthanna Gordon, PhD. Diagnostic Error in Internal Medicine, JAMA Arch Intern Med. 2005;165(13):1493-1499 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/486642
  4. Alex Dunbar.  Celiac Disease is misdiagnosed in 97% of all cases despite growing awareness, CNY Central. Feb 2012. https://cnycentral.com/news/local/celiac-disease-is-misdiagnosed-in-97-of-all-cases-despite-growing-awareness
  5. Diagnostic Errors More Common, Costly And Harmful Than Treatment Mistakes. John Hopkins Medicine, Apr 2013.  https://www.hopkinsmedicine.org/news/media/releases/diagnostic_errors_more_common_costly_and_harmful_than_treatment_mistakes

  6. Leading Causes of Death, Centers for Disease Control and Prevention. Source: Mortality in the United State, 2019, data table for figure 2.  https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm

  7. Hardeep Singh, Ashley N D Meyer, Eric J Thomas. The frequency of diagnostic errors
    in outpatient care: estimations from three large observational studies involving US adult populations.  BMJ Quality & Safety Online First, published on 5 May 2014 as 10.1136/bmjqs-2013-002627 https://qualitysafety.bmj.com/content/qhc/early/2014/05/05/bmjqs-2013-002627.full.pdf
  8. Telehealth: A quarter-trillion-dollar post-COVID-19 reality?, McKinsey & Company. Healthcare systems and Services May 2020

  9. David L. Feldman, MD, MBA, FACS. How COVID-19 Accelerated Telemedicine Use, The Doctor Company, Updated May 2020  https://www.thedoctors.com/articles/how-covid-19-accelerated-telemedicine-use/
  10. David L. Feldman, MD, MBA, FACS. How COVID-19 Accelerated Telemedicine Use, The Doctor Company, Updated May 2020  https://www.thedoctors.com/articles/how-covid-19-accelerated-telemedicine-use/
  11. What is Diagnostic Error? Society to Improve Diagnosis in Medicine.  https://www.improvediagnosis.org/what-is-diagnostic-error/

  12. International Classification of Diseases, (ICD-10-CM/PCS) Transition – Background. CDC, National Center or Health Statistics. https://www.cdc.gov/nchs/icd/icd10cm_pcs_background.htm

  13. List of medical symptoms, Wikipedia. https://en.wikipedia.org/wiki/List_of_medical_symptoms
  14. Kaveh G. Shojania, M.D., and Elizabeth C. Burton, M.D. 

    The Vanishing Nonforensic Autopsy, The New England Journal of Medicine. N Engl J Med 2008; 358:873-875 

  15. Hardeep Singh, MD, MPHTraber Davis Giardina, MA, MSW, et al.  Types and Origins of Diagnostic Errors in Primary Care Settings, May 2013   JAMA Intern Med. 2013;173(6):418-425.
  16. Kelly Young – Edited by David G. Fairchild, MD, MPH.  Half of Physician Time Spent on EHRs and Paperwork, NEJM Journal Watch. Sep 2016 
  17. Mark L. Graber, MDNancy Franklin, Ph.D.Ruthanna Gordon, Ph.D. Diagnostic Error in Internal Medicine, JAMA Internal Medicine Arch Intern Med. 2005;165(13):1493-1499
  18. Hardeep Singh, Gordon D Schiff, Mark L Graber Quality & Safety, The global burden of diagnostic errors in primary care Vol 26, Issue 6  https://qualitysafety.bmj.com/content/26/6/484
  19. Tejal K Gandhi, MD, MPH, Hardeep Singh, MD, MPH.   Reducing the Risk of Diagnostic Error in the COVID-19 Era, Journal of Hospital Medicine, J. Hosp. Med. 2020 June;15(6):363-366.
  20. Julie Abimanyi-Ochom, Shalika Bohingamu Mudiyanselage, Max Catchpool, et al. 

    Strategies to reduce diagnostic errors: a systematic review, BMC Medical Informatics and Decision Making, Article number: 174 (2019


Originally published February 19, 2017. Updated April 6, 2021. 

I turned the corner and there it was. The Death Star, as locals call it, because it’s star-shaped, imposing, and has a helipad on the roof. Also known as the Queen Elizabeth University Hospital in Glasgow—a state-of-the-art, 14-floor hospital completely interlinked, part of the National Health Service in Scotland—it was the site of the Non-technical Skills for Surgeons (NOTSS) Master Course I was invited to join.

In my exploration of what makes a good surgical team, I came across “Teamwork Assessment Tools in Modern Surgical Practice.” That article inspired me to write Can Surgery Teamwork Save Your Life?, describing one of the best assessments, Non-technical Skills for Surgeons (NOTSS).

Any excuse to travel is all right with me. The Royal College of Surgeons-Edinburgh offered a NOTSS Master course on a day I was available.  So I headed to Glasgow for a few days of Scottish music, single malt scotch, and museums before the course.

Training surgeons in non-technical skills

NOTSS is a program to train surgical residents (and more senior physicians) in non-technical skills. They are specifically referring to the behavioral elements of optimal surgical performance.

ADD_THIS_TEXT
 

UK surgeons who are accepted into the Royal College are called Mr, Miss, Ms, or Mrs rather than doctor.  Mr. Simon Paterson-Brown and Mr. Simon Gibson kicked off the day with the usual medical statistics about using checklists in the operating room, or theatre, as it’s known in the UK. Routine use of checklists halves surgical mortality, from 1.5% to 0.8%

Using a checklist might have prevented Sheila Hynes death in March 2017, after her new heart valve was put in upside down. The two Simons asked us, “What goes wrong in your theatre?” Reasons for errors include the following:

      • time pressures
      • distractions
      • last-minute changes
      • inadequate preparation
      • faulty assumptions
      • inadequate help
      • incomplete information, and
      • the “system”: people, resources, and how they are dispersed.

Human factors, leadership, and communication, all included in non-technical skills, are the top three contributors to Sentinel Events. These are unexpected events in a healthcare setting that kill or harm patients and that are unrelated to the patients’ illness.

As I learned, NOTSS is not about:

      • bad guys,
      • remediation,
      • catastrophic failure,
      • blame/attribution, or
      • extraordinary events.

And there is no single vaccination for immunity.

NOTSS is about normal people, places, organizations, and systems. It’s about recognizing complexity and optimizing performance.

Other stories by this author: A Fatal Medical Error: Lack of Care or Lack of Caring?

Situational awareness

High on the list of necessary skills for effective surgeons is situational awareness. This is the state of being aware of what’s around you even as you focus on the task of surgery.

Check out this video to test your own situational awareness.

Here are some ways to enhance situational awareness:

      • Pre-task briefing
      • Sterile cockpit concept: Avoid unnecessary distractions
      • Active information gathering through scanning
      • Self-checking
      • Cross-checking: Ask other team members
      • Re-check information after interruption or distraction
      • Use open rather than leading questions
      • Encourage junior staff to speak up if concerned
      • Realize that even experts can make errors…and put a heart valve in upside down
      • Have a safe word, such as “watermelon,” which means stop. And then use it. And stop

Self-check and CUSS

I’M SAFE is the mnemonic for a self-check list at the beginning of the day and when starting new or major procedures. Are you having any negative effects from the following?

      • Illness
      • Medication (e.g., codeine for a toothache, antihistamines for a cold, coping with a runny nose behind a surgical mask)
      • Stress (personal relationships and time pressures)
      • Abuse (substance and alcohol, and its after-effects)
      • Fatigue
      • Emotion (rudeness, anger, aggression, and personal grief) and Eating (impact of hypoglycemia)

While observing surgeons, use CUSS for graded assertiveness:

      1. I’m CONCERNED about what you’re doing
      2. I don’t UNDERSTAND why you are doing what you’re doing
      3. I am SERIOUSLY worried about what you’re doing
      4. Please STOP what you are doing

In 1977, KLM Flight 4805 and Pan Am Flight 1736 collided on the runway in Tenerife. This was the deadliest airplane accident in history at that time, killing 583 people.

The pilot was Captain Veldhuyzen van Zanten, KLM’s chief of flight training and one of their most senior pilots. He took off without clearance, smashing into the other 747 on the runway.

In 2009, Captain Chesley “Sully” Sullender landed a crippled airplane on the Hudson River, with no loss of life. In the former, other crew members were reluctant to question the captain. They died. In the latter, the team concentrated on doing the right thing at the right time. They lived.

What do high-performing teams have in common?

According to TeamSTEPPS, they

      • Are responsible for ensuring that team members are sharing information, monitoring situational cues, resolving conflicts, and helping each other when needed
      • Manage resources to ensure the team’s performance
      • Facilitate team actions by communicating through information exchange sessions, such as after-action reviews
      • Develop norms for information sharing; and
      • Ensure that team members are aware of situational changes to plans

Good quality operating room leadership leads to decreased errors, reduced costs, improved safety, and increased compliance with standard operating procedures (SOPs).

Despite that, 47% of surgeons believe the decisions of the “leader” should not be questioned. So did the crew members of Captain van Zanten. And, contrast that with the present time where only 7% of pilots have that belief, a smaller percentage after changes were implemented following the Tenerife crash.

The bottom line when it comes to non-technical skills for surgeons

One solution is to send your surgeons abroad for NOTSS training. Another is for them to take the course at the annual American College of Surgeons meeting.  This is where there is often a workshop on this topic.

The book, Enhancing Surgical Performance: A Primer in Non-technical Skills,* offers a detailed road map for “structuring observation, rating, and feedback of surgeons’ behaviors in the operating theatre.”

Anyone involved in surgery—surgeons, nurses, residents, students—will learn what to look for and how to perform to increase staff well-being and decrease patients’ deaths and errors in the surgical suite.

I use this assessment with my surgeon coaching clients as I observe them in the operating room with their teams. The experience changes how they approach the surgery process. Becoming adept at non-technical skills literally changes lives for the better—patients’ lives.

As the great sage, Yoda said,

“Do. Or do not. There is no try.”

Resources:

1.NOTSS Website: https://www.notss.org/
2. Industrial Psychology Research Centre, University of Aberdeen (all handbooks)
3. Intercollegiate Surgical Curriculum Project (NOTSS handbook)


*Indicate an affiliate link. We may make a small commission if you purchase this book using this link. It will not affect your price, but it does help us do our work.


Published 6/3/17. Reviewed and updated 12/3/20.

Chronic wounds aren’t typically something most people think about. If there is a break in the skin or deep tissue, nature takes over and our bodies begin the healing process.

However, for some adults, especially those who are older or managing health conditions, wound healing – particularly if the wound is chronic – is not as easy.

Chronic wounds are common 

Every year, more than 6 million people in the U.S. are affected by chronic wounds such as pressure injuries and foot ulcers[1]. Unlike acute wounds from a surgical incision or an injury, chronic wounds often occur in people with conditions like immobility or diabetes.

These types of wounds don’t necessarily show signs of healing within 30 days. If wounds don’t heal properly, they can lead to some very serious complications.

Because of the associated complications, chronic wounds put a significant financial strain on the health system. It’s estimated that $25 billion is spent annually in the U.S. to treat these wounds. This, plus the inconvenience and setbacks of people afflicted with chronic wounds makes it critical that healthcare providers help patients reduce the risk of wound complications.

Risks factors for chronic wounds

Some of the factors that put a person at higher risk for chronic wounds, include the following [2]:

  • older age
  • hypertension
  • poor nutrition
  • chronic lung disease
  • diabetes
  • obesity 

Self-care can make a difference in chronic wound care

I am a nutrition scientist and researcher at a global healthcare company that produces science-backed nutritional therapies. I’ve specialized in wound healing for more than two decades.

My passion is to empower patients and their caregivers with self-care strategies to support continued wound healing at home, as directed by a physician. By focusing on the following areas of wound care, healthcare providers can help patients and caretakers stay on top of their care plan in order to achieve the best outcomes possible.

  • Ensure proper wound dressings and care

To ensure care is continued long after a hospitalization or clinic visit, clinicians should talk to their patients about the appropriate steps to clean their wound and keep a fresh dressing applied to it. This will help prevent germs from contacting the wound while absorbing fluid that drains from the site that could damage the skin surrounding it.

While the best methods for dressing will depend on the individual’s specific type of wound, there are general steps that patients and caregivers should become familiar with handling at home. These include,

      • cleaning the wound each time the dressing is changed,
      • applying a fresh dressing, and
      • possibly using a compression stocking or bandage to help improve blood circulation and promote healing[3].

Lastly, protecting the wound site is important. Patients should be coached to take steps to avoid any additional trauma to the wound. This can help reduce additional setbacks.

For example, if a person has a foot ulcer, it helps to make sure that any shoes or slippers are not aggravating the wound site. Further, directing patients to elevate the affected foot above heart level for 15 to 30 minutes a few times per day may help with swelling and improve blood flow.

  • Don’t underestimate the power of nutrition

Nutrition is often an overlooked part of wound care, however, it can support healing from the inside, out.

Our bodies are designed to heal skin and tissue damage, but only if they have the right tools to make it happen. Good nutrition is one of those critical tools.

For each stage of the healing process, specific nutrients are required. If a person isn’t getting enough of the right nutrients, the wound-healing process can be delayed.

The body needs additional calories as well as protein, amino acids, vitamins, and minerals to generate new tissue at the wound site.

Some of the specific nutrients to prioritize include the following:

        • arginine and glutamine, important amino acids during the wound healing process that provide building blocks for new tissue. 
        • Hydrolyzed collagen is necessary to stimulate the production of internal collagen at the wound site.
        • HMB (short for β-hydroxy-β-methyl-butyrate) helps slow muscle protein breakdown
        • Zinc supports immune function and skin integrity
        • Vitamins C, E, and B12 help strengthen the new skin and to help get more oxygen to the wound site.

It can sometimes be difficult for a patient to get enough of these key nutrients from diet alone, especially if they are malnourished or managing other health conditions.

Recovery during hospitalization or from illnesses can also take a toll on a patient’s appetite. It can also impact their ability to tolerate certain foods.

When a balanced diet is not enough, there’s a clinically-backed nutrition supplement that supports the wound-healing process by providing essential nutrients that have been shown to enhance collagen formation in as little as two weeks which healthcare providers can recommend.[4]

  • Counsel on the signs of infection

With chronic wounds, there’s no precise timetable for healing. Each patient is unique, and how quickly and efficiently a person’s body recovers from a chronic wound can depend on several factors, ranging from the type and size of the wound to their overall health and nutrition status.

In general, the larger the wound, the longer the recovery process will be. For these patients, enlisting a caregiver for support can be a helpful strategy to make the recovery process easier.

  • When to ask for help

Throughout healing, it’s essential that patients learn how to recognize the signs of a wound that is getting worse instead of better – and when it’s time to seek additional care. These can include,

      • increased levels of pain and discomfort
      • redness
      • pus, or discharge from the wound site, 
      • sensitivity 
      • swelling
      • a noticeable odor[5]

Remind patients and caregivers to call immediately if they experience any of these symptoms, to ensure the infection is caught and addressed early.

Related Content:  What You Need to Know About MRSA and What to Do About It

Support patients during the age of COVID

It’s difficult to predict what the coming months will bring as the COVID-19 pandemic continues. We must recognize that individuals with chronic wounds may feel particularly vulnerable while navigating the healthcare system with its heightened health and safety measures.

This presents healthcare providers with an opportunity to engage with these patients in new ways. From reviewing the best methods for at-home wound care to discussing lifestyle changes and recommending helpful nutrition supplements.

These are simple steps that can go a long way in offering patients and their caregivers the proactive means to take control of their health.

Expanding the channels of support to include telehealth and virtual platforms could also be a valuable way to provide reassurance and emphasize the appropriate steps for at-home care. It also helps avoid unnecessary visits to doctors’ offices, hospitals, or other care facilities for the time being, as appropriate.

Related content: Doximity’s New Telehealth Platform Makes it Easy to Connect

The bottom line

The best way to ensure effective self-care, monitor wound healing, and answer questions as they arise is by scheduling regular check-ins. This allows clinicians to maintain an accessible and open dialogue with patients and caregivers as they deal with a chronic wound.

References:

[1] Sen CK, Gordillo GM, Roy S, et al. Human skin wounds: a major and snowballing threat to public health and the economy. Wound Repair Regen. 2009;17(6):763-771. https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1524-475X.2009.00543.x

[2] Guo S, Dipietro LA. Factors affecting wound healing. J Dent Res. 2010;89(3):219-229.  https://journals.sagepub.com/doi/abs/10.1177/0022034509359125

[3] InformedHealth.org. Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG); 2006. What are the treatment options for chronic wounds? 2006 Oct 17 [Updated 2018 Jun 14].  https://www.informedhealth.org/what-are-the-treatment-options-for-chronic-wounds.2706.en.html?part=behandlung-ko

[4] Williams JZ, et al. Ann Surg. 2002; 236:369-374.3 Jones, et all, Surgical Infections, 2014. https://journals.lww.com/annalsofsurgery/Abstract/2002/09000/Effect_of_a_Specialized_Amino_Acid_Mixture_on.13.aspx

Jones, et al., Surgical Infections, 2014;15(6):708-712.): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4268587/

[5] Frank C, Bayoumi I, Westendorp C. Approach to infected skin ulcers. Can Fam Physician. 2005;51(10):1352-1359https://www.cfp.ca/content/51/10/1352 

 

All industries need translators and interpreters who are trained in different languages. Although some items, symbols, and/or actions may be universally understood, you still need to convey subtle meanings and instructions across cultures. It is especially important to overcome language barriers in healthcare. That is why the need for medical translation and interpretation is so critical.

Translation and interpretation activities in the health domain are numerous. They can range from simultaneous or consecutive interpretation, translation of medical files, correspondence between doctors and patients, and much more. This article will provide a complete overview of language translation and interpretation in healthcare. We will attempt to answer the questions:

  • Who does it?
  • How does it work?
  • How much does it cost?

And we will provide some predictions for the future.

Medical translation vs medical interpretation

In the language services industry, we differentiate between two concepts related to transferring the meaning from one language to another: interpreting and translation.

  • Interpreting refers to the act of real-time, in-person transferring of communication from one language to another.
  • Translation refers to written documents and is usually not carried out in real-time.

These activities are distinct and require different training and skillsets. However, it is common to use the term medical translation and medical interpretation interchangeably. I will try to point out the distinctions as we explore the profession in this article.

Why medical translation and interpretation are so important

Medical translation and interpretation together comprise one of the most sensitive fields within the industry of translation. Unlike some other forms of translation and interpretation, there is zero-tolerance for mistakes in healthcare.

This is because incorrect translation might harm someone’s health or well-being. It could lead to interventions, like surgery or prescription of powerful medications that are associated with a risk of serious complications. Thus, it is clearly an activity that has to be carried out by highly proficient people who exercise a great deal of concern in order to ensure the quality of their work.

  • Worldwide patterns of migration drive demand

The medical translation field has become even more critical with the rise of migration. Large numbers of people move from one country to another without speaking the language. When they require health care, particularly in emergencies, they can be in trouble without interpreters.

For many people who are outside the industry, it may seem surprising that there is such a high demand for language interpretation in medical services. However, statistics show that it’s anything but surprising. For example, in the US, more than 45 million people don’t speak English as their primary language. And, an additional 21 million said that they don’t speak English “very well”.

  • The impact of international tourism

Along similar lines, until the onset of the COVID-19 pandemic, international tourism was increasing every year.  Again, this can lead to people becoming stranded in emergency rooms where they cannot speak the language. Again, this is where medical interpreters come in.

  • Medical tourism and interpretation

Another opportunity for increased demand in healthcare interpreting is medical tourism. This is an industry that has been on the rise with the expansion of international flight connections and globalization in general.

Medical tourism occurs when people from countries, like the United States with a high costs of healthcare choose to get services in countries where healthcare is high quality, but much cheaper. They often combine it with a vacation.

It is most often done in the fields of cosmetic surgery and dentistry. However, you can now find overseas opportunities to receive a broad range of services, including joint replacements, organ transplantation, and cardiovascular surgery, amongst others.

Naturally, medical tourism’s only issue is the language and cultural gap. This is why many organizations who are dealing with these types of medical services often have language interpreters on call.

Language barriers healthcare medical-tourism

The increasing popularity of medical tourism is one of several drivers for more and better medical translation services (Graphic source: iStock)

According to experts, both medical tourism and telemedicine will increase the demand for interpreting in healthcare services in the near future.

What is language translation in healthcare settings?

In general, medical translation (encompassing translation and interpretation) is defined as any process of translation that serves healthcare professionals to provide the necessary treatment for patients who speak (or read) another language.

As you are aware, it’s incredibly important that medical professionals are able to communicate with their patients effectively. As I have mentioned that’s not the case, the entire care and treatment process is endangered. Medical interpreting and translation, therefore, primarily deal with these tasks:

  • simultaneous interpreting of doctor-patient communication
  • translation, including but not limited to, of any of the following documents: 
      • doctor-patient written correspondence
      • patient’s medical history in another language
      • lab test results, findings, and so forth.

When you need any type of medical translation, you should contact experts who are experienced in that particular field. Don’t contact just any translation agency or company – it’s important that the company you’re working with has had previous experience with these types of documents because they have special terminology.

You need to specify if you need medical interpreting or medical translation

When you’re looking for language services, you need to specify whether you’re looking for interpreting or translation. If you want someone to be in the hospital or at a doctor’s appointment with your family member, look for interpreting services.

If you want to get a medical document, lab test results, or any other written document translated to another language, you’re looking for a translation.

The benefits of interpreting include an opportunity to have a private, intimate conversation with a doctor and to ask questions as they pop up into your mind. It’s also much faster than translation because it has to be done in real-time. The drawback is that there is more room for error as the interpreter has to react quickly and sometimes under pressure.

Translation, on the other hand, is done at a much slower pace. As a result, the translator has the opportunity to step back and take the time needed to decrease the chances of error. However, this may not be applicable in a medical setting because information usually has to be processed as soon as possible.

Put your self in the patient’s shoes when thinking about medical translation and interpretation

Just imagine a regular visit to the doctor and being unable to explain what the issue is. Simply put, healthcare heavily relies on the patient’s subjective and objective description of what they are experiencing. Further, care and treatment depend on the fact that patients understand, trust, and listen to doctors’ instructions. In fact, non-native English speakers in the US often report that they are unsatisfied with the medical care they receive and they risk medical errors more than native speakers.

Unfortunately, the vast majority of healthcare organizations do not provide sufficient interpreting services. Usually, people who help non-native speakers are found “randomly.” They are family members or friends who speak both languages, not trained interpreters.

There are many problems with involving family members in interpretation including violating the patient’s privacy, failure to fully translate what the patient said because of embarrassment on the part of the patient or the family member. Sometimes there is a failure to fully understand the question or the answer.

Unfortunately, in many healthcare settings, patients have to rely on family members or secure healthcare interpreting services on their own. Sometimes the healthcare organization will help find the interpreter but the patient will be charged for the extra expense. Sometimes, the patient has to find a language professional on their own and pay out of pocket.

Telephonic services for medical interpretation

Another increasingly used language service is hiring telephone interpreters in a medical setting. In recent years, many big translation and interpreting companies have started expanding their offer portfolio to cover this service as well.

If you’re considering hiring a telephone interpreter in a healthcare setting, make sure they are certified medical interpreters. The issue with tele-interpreters is that many people and organizations around the world offer this service with varying quality. Unfortunately, it may be hard to differentiate between expert interpreters and amateurs.

If you’re sure you have access and cooperation set up with a certified medical telephone interpreter, that’s a good solution. If you’re not sure, it’s better to opt for some other interpreting options.

The price of medical interpretation and translation

The greatest issue with language interpretation in healthcare is that organizations don’t contract with regular interpreters because of the financial burden these services may impose.

Among all translation niches and fields, medical is one of the most expensive ones. Also, simultaneous interpretation is notably more expensive than a written translation.

Affordable services that can help you with medical translations are widely available. You can search the internet for medical interpretation and translation services to see what kinds of prices are being charged.

You will find that the pricing may differ wildly from one organization to the next. For example, some healthcare clinics offer free interpreting services for patients who don’t speak the language. Others will charge it as an additional service along with your medical bill.

Remember, the benefits far outweigh the costs when you decide to hire a professional medical interpreter compared to a non-trained professional.

How to carry out professional and accurate language interpreting in healthcare?

If you’re a healthcare professional who is communicating with a non-native speaker for the first time, a patient who doesn’t speak a foreign language or an intermediary, here are some of the basic tips to keep in mind during the interpreting process:

  • Introduction

It sounds obvious, but it would surprise you how many times people forget about this. Present all the people who are taking part in the conversation: patient, patient’s partner, parents, and so forth.

  • Speak slowly

Keep in mind that someone will be translating everything you say. Slow down the tempo and speak clearly. This is especially important if you are a naturally fast speaker.

  • Speak to each other

When an interpreter is present, many people feel like they should speak to them instead of the doctor/patient. You should talk directly to the doctor/patient instead.

  • Take breaks more often

Don’t combine dozens of sentences and questions and wait for the interpreter to make sense of all that. Take frequent breaks from speaking to give the interpreter enough time to present what you just said.

  • Set aside more time

When you have an appointment with an interpreter, it will last at least twice as much as a “regular” appointment. Make sure you take that into consideration when you schedule these types of appointments.

For many people, this is a new situation that takes some getting used to. Namely, a visit to the doctor is, for most people, a private and intimate process. It involves communication about your personal issues with a person you trust.

When an interpreter enters this equation, the social dynamics of the doctor-patient conversation can become a little awkward. Nevertheless, it’s a prerequisite for good understanding and to ensure that a patient receives proper care.

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Conclusion

Medical interpretation is sensitive. It is best when it is carried out by professionals. If a healthcare organization doesn’t have its own interpreter (which it probably doesn’t), you can hire someone to help you. Make sure you hire someone with experience in healthcare particularly because mistakes really can be costly.

Avoid getting interpreting services from amateurs and non-trained persons if at all possible. As you probably know, even the tiniest bit of information that’s exchanged in doctor-patient communication is important. Omitting something or adding a fact that’s not there can seriously harm care and treatment. To avoid this, I recommend you work with professionals.

The Doctor Weighs In is very lucky to have had a long-standing relationship with the Physician-Patient Alliance for Health and Safety (PPAHS), one of the premier patient safety organizations in the country. The Founder and Executive Director, Michael Wong, has been a frequent contributor has also arranged for others in his network to write for us as well. We are in awe of the work PPAHS does and are pleased to share the following news from their Press Release:

A telehealth project to improve treatment and adherence for patients at highest risk for stroke has been launched by PPAHS and supported by a BMS-Pfizer Alliance Grant

The PPAHS Afib telehealth project

Today, PPAHS announced the launch of a new, free virtual clinic and website, Virtual Patient Care in response to the COVID-19 crisis. It was created to meet the pressing needs of patients with atrial fibrillation (Afib) who are at the highest level of risk from a stroke. The project also aims to help Afib patients cope with the challenges presented by COVID-19.

According to Michael Wong, JD, Founder and Executive Director of the Physician-Patient Alliance for Health & Safety, the organization that conceived of and managed the project:

“Under current COVID-19 conditions, patients face the burdens of social distancing and increased difficulty in reaching clinicians busy with emergencies. Telehealth has proven essential in addressing patients’ pressing health needs and ensuring good patient-to-clinician dialogue. With today’s launch of Virtual Patient Care and the CV Virtual Clinic, vital telehealth benefits are now also extended to Afib patients in need.”

The goal of Virtual Patient Care is to foster an adherence rate greater than the reported 50% for patients at the highest ranges of stroke risk. 

Unrestricted grant from BMS-Pfizer

The free telehealth service is supported by an unrestricted grant from the BMS-Pfizer Alliance.  PPAHS is using the funds to establish the clinic’s web platform and chat lines.

The CV Virtual Clinic and Virtual Patient Care will also use the efforts, involvement, and/or resources of the following organizations:

“Because people with Afib are at a five-times-higher risk of having a stroke, adhering to the medication plans prescribed by their doctors is of the utmost importance,” said Mariell Jessup, Chief Medical Officer for the American Heart Association. “Being able to provide people with the support they need to manage their Afib at home during this time may help avoid additional health risks.”

The benefits of telehealth

Telehealth has proven essential in connecting patients with their healthcare providers in the current COVID-19 crisis. It also has important additional benefits as follows:

  • Telemonitoring has been shown to improve medication adherence in Afib patients, and
  • Research shows that some virtual clinics are “an effective alternative to the usual care model for many patients.”

“It’s hard to imagine what the COVID-19 crisis would be like without the benefits of telehealth, which is protecting both patients and caregivers on the front lines of this fight,” said Sue Koob, MPA, Chief Executive Officer of the Preventive Cardiovascular Nurses Association. “Cardiovascular disease remains a leading killer of Americans, responsible for nearly 650,000 U.S. deaths, killing fully one in four Americans, every year. Today’s announcement means better, safer education and adherence for Afib patients, which is very much needed at this time of the global health crisis.”

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Who will use the virtual clinic?

Patients referred to the CV Virtual Clinic will be those diagnosed with Afib or who have been treated with a reversal agent and then are restarted on anticoagulant therapy.

ADD_THIS_TEXT
 

The clinic is intended to help Afib patients to keep their treatment in accordance with the American Heart Association’s 2019 Afib guidelines. The approach includes maintaining online resources, including a team of clinicians tasked with helping educate patients on maintaining adherence to their anticoagulant therapy.

Mellanie True Hills, founder of StopAfib.org, a patient advocacy organization for those living with atrial fibrillation explains it this way:

“In our experience, medication nonadherence among Afib patients often stems from not truly understanding why they are taking a specific medication or what that medication does for them. We are proud to support the CV Virtual Clinic, which will provide individualized support to Afib patients in understanding their medications and the importance of taking them properly.”

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Andrea Baer, Executive Director of Mended Hearts, a national and community-based, non-profit, heart patient support network adds,

“This resource will be so helpful to Afib patients who need resources and support during this time,” We are excited to be able to offer this to our members.”

The PPAHS clinician team will monitor each patient. They will also be available to answer questions through a chat line or over the phone. No medical advice or prescribing will be done by PPAHS. This is a free service provided by PPAHS.

About the Physician-Patient Alliance for Health and Safety (PPAHS)

PPAHS is an internationally ranked top-100 patient safety organization, Physician-Patient Alliance for Health & Safety is a national advocacy force for addressing patient health and safety priorities that are shared by patients, physicians, regulators, and industry. We seek to ensure that the best medications, medical inventions, and technology that can improve care and reduce costs are employed. PPAHS works to advance patient health and safety by developing and highlighting best practices and recommendations through better use and application of clinical practices and experiences, information technologies and checklists, and healthcare information. As a voice in support of ideas and innovation that can improve care, we encourage a health ecosystem that fosters a culture of patient safety. For more about PPAHS, please go to www.ppahs.org.

About StopAfib.org

StopAfib.org was founded in 2007 by Mellanie True Hills, an atrial fibrillation survivor, to improve the quality of life for those living with atrial fibrillation and to raise awareness of afib and reduce afib strokes. HON Code Certified StopAfib.org is a patient-to-patient resource and the most visited patient arrhythmia site. It features the latest afib news and videos along with information about atrial fibrillation and stroke symptoms, causes, risks, and treatment. The Atrial Fibrillation Services Locator helps atrial fibrillation patients find hospitals, atrial fibrillation centers, electrophysiologists, and surgeons that specialize in treating afib. StopAfib.org also features atrial fibrillation patient resources, a newsletter, the Atrial Fibrillation Blog, the StopAfib Discussion Forum and Community, and the StopAfib YouTube Channel that brings top afib doctors to patients. For more information, visit www.stopafib.org or contact Mellanie True Hills at 940-466-9898.

This is a sad tale of a fatal medical error, lack of care and lack of caring.

***

Bob and Lorraine, both in their 60s, were my landlords. They lived across the nearly two-lane road in the house they built over Adobe Canyon Creek in Sonoma County, California.I was Bob and Lorraine’s doctor. This was not in the come-to-my-office sense. Rather it was in the I’m-the-only-medical-person-in-the-family sense.

Bob

Bob developed a Dupuytren’s contracture. This is a condition which is where a finger, or fingers, is drawn down toward the palm. The connective tissue thickens and shortens, so moving the affected finger(s) is difficult.

The treatment is surgery. I recommended he see one of the top plastic surgeons in town. Another friend did Bob’s anesthesia, blocking the nerves leading to the hand, much as dentists block nerves in your mouth. This allowed Bob to be awake during the operation.

I assisted with the case and we all—patient, surgeon, assistant, and anesthesiologist—chattered together during the case, sharing jokes and laughing.

Bob’s hand healed well and he would often hold it up, showing the scar and proudly saying, “Maggi is my doctor.”

Lorraine

Lorraine and I were particularly close. She listened to me in good times and bad. She saw me through each of my parent’s deaths, medical residency, my first years of medical practice, moving to Denver, and a devastating break-up.

We kept in touch through telephone calls and writing. I looked forward to each handwritten letter. Lorraine had been a looker in her younger years and Bob had swept her off her feet as a handsome and cosmopolitan young man from an old New Orleans family.

Each time I visited the Bay Area from Denver, I added extra time to drive over the Golden Gate Bridge to visit them. By the time I turned the car around in the circular driveway, Lorraine and Bob had stepped off the porch to greet me. Sonoma County always felt like home.

We hugged, walked up the three stairs to the threshold, and sat in the living room. After a brief catch up, Bob drove Lorraine and me to the local family-owned restaurant.

Transition

Bob’s eyesight began failing from macular degeneration. This, unfortunately, is a common cause of age-related blindness. The macula, or central retina, degenerates and, therefore, cannot capture images to send to the brain to interpret. Twice, he nearly had a car accident as he turned onto the main highway.

Lorraine was getting increasingly forgetful and was anxious about becoming senile. Their only child and his wife, Glyn, and Jane coaxed them to move into transitional housing to be near them, about 120 miles away.

Bob and Lorraine had lived in their house for decades. They left the area and their friends reluctantly and with many tears.

Our roles reversed

I continued my tradition of visiting Bob and Lorraine whenever possible. I usually stayed with their son and his family. Jane told me Lorraine could scarcely contain herself when she knew I was coming to visit.

She was happy from the time I called to let her know I was coming until long after I departed. I have often thought since then of the power in spending time with people—in just showing up.

Gradually, our roles began reversing. Lorraine and Bob had always looked after me from afar. Now I was looking after them, adding whatever little I could to Glyn and Jane’s excellent caregiving.

The steady decline

Lorraine’s “forgetfulness” was early dementia. She steadily declined from independent living in their transitional housing facility with daily assistance to needing more care than the facility could provide. She had to move to long-term care.

All the while, Bob’s macular degeneration progressed to where he could no longer read. The closest facility for Lorraine was two hours and three bus routes from the apartment she had shared with Bob. Bob, virtually blind, visited her once or twice every day. Lorraine often did not recognize him. But he stayed, talking with her and holding her hand.

The hospitalization

Bob became ill with a chest infection and was treated as an outpatient. After treatment, he was admitted to the hospital in a confused state.

I see spiders,” he said to Glyn as he picked at the air from his hospital bed.

Glyn told Bob’s doctors he had been a perfectly coherent, a spry 88-year-old before his hospital admission. The doctors seemed indifferent.

As often happens with old people, after his acute hospitalization, Bob was transferred to a nursing home. When he arrived, the staff immediately returned him to the hospital, saying he was too sick to be in a nursing home and suggested further evaluation and treatment.

I flew from Denver to California to be with Bob and his family. I wanted to see what I could do to sort out Bob’s medical care.

But, he died before I got to his bedside.

Reconstructing the cause of death

On the surface, this might seem to be just another death of an elderly man. Often when elderly spouses are separated, one will die.

As I sat with the family the day after Bob died. His granddaughter Ann, in her final year of medical school, and I reconstructed the details of Bob’s final days.

Bob’s physicians had started him on antibiotics a few weeks before his death. As we listened to the course of his illness and the timing of events, Ann and I began asking questions.

Tell me again how he was acting,” I asked.

Bob was seeing people who weren’t there and talking nonsense,” Glyn said.

I recalled the spiders. These hallucinations sounded like liver failure, usually caused by chronic alcohol use, but also caused by certain medications with a similar effect on the liver, especially in the elderly. Bob wasn’t a drinker.

Was he yellow?,” I asked.

Yes, at the end.”

Another sign of liver failure.

Do you remember what antibiotics he was taking?,” I asked.

No.”

Was he getting regular blood tests while on the antibiotics?

I don’t know. He had blood drawn when he was in the hospital.”

Too few facts, but Ann and I looked at each other. I mentioned medication-induced liver failure.

Ann nodded her head and said, “That’s what I’ve been thinking.”

A medical error: Lack of care or lack of caring?

As near as we could tell from the limited facts, it appeared the antibiotics had damaged Bob’s liver, leading to his confusion, jaundice, and death.

In general, medications are processed by the liver or the kidneys before being excreted from the body. Some medications have well-known side effects on the organs. Specific antibiotics are notorious for this, especially in the elderly.

Related story: Nursing Errors Led to my Son’s Unexpected Death

The standard of care is to check the liver enzymes in the blood. If the levels are up, it means the liver cells are being damaged. It was not clear to me Bob’s liver enzymes had been regularly checked.

It appeared to me that his physicians paid no attention to Glyn. And, that they considered Bob to be a confused old man who was grieving over separation from his wife. Perhaps they may have even thought of him as an old geezer not worth saving.

Too little, too late

A couple of days before Bob died, his physicians recognized he was jaundiced. His skin and the “whites of his eyes” were yellow because of liver failure. Bob was most likely confused because of the build-up of toxins, such as ammonia, from his liver’s inability to process them.

Bob probably died of the side effects of a medication toxic to his liver.

Had Bob been cared for by clinicians who remembered to check his liver enzymes, he might have lived through his illness. His medications could have been stopped or altered when the liver enzyme levels were elevated.

Had Bob’s care been coordinated among his many physicians, both outside and inside the hospital, I don’t believe he would have died from this event. He would have been alive for his granddaughter’s graduation, with honors, from medical school three months later.

First, do no harm

Failing to check liver enzymes in an elderly patient on certain medications is malpractice.  “Old” and “done for” are not synonyms. Primum non nocerum—first, do no harm.

Eventually, I moved on from my fourth-grade dream of being a small-town family practice doctor to working on health policy at the national level. I wanted to play a role, however tiny, in fixing our broken healthcare system.

Looking back on all my work in clinical care, regulation, health policy, public health, and business, through my journey through nearly every component of the medical industry, a driving force and motivating factor in all my work was my friend Bob and the medical error that killed him.

***

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***

This story was first published as “What Killed Bob, Lack of Care or Lack of Caring” in November 2017. It is being republished as part of a series focused on medical error and narrative-based medicine.

 

 

Medical science has always embraced advancing technology. And, it continues to do so today, changing nursing practice in ways that would have been unimaginable in the past.

Here are just a few of the ways that technology is being used in nursing:

  • Remote monitoring assists in diagnosis, treatment, and monitoring of chronic illnesses.
  • Modern diagnostics, analytics, and informatics help keep nurses abreast of local and global health trends.
  • Electronic nursing tools ensure timely and effective intervention
  • Remote education and training help healthcare professionals stay up to date with advances in science.[mfn]Jones, Diana P.; Wolf, Debra M (2010) Shaping the Future of Nursing Education Today Using Distant Education and Technology[/mfn] 

It is no wonder that new technologies are guiding more and more of what we do.

Delivery of care evolves with advances in technology

Good nursing practice is based on the provision of timely, evidence-based care including for monitoring, diagnosis, and treatment. This ensures the best possible patient outcomes and experience.

It is important to note, however, that the way this nursing care is actually delivered evolves with advances in technology. Technological advances and resultant changes in day-to-day nursing practice are happening faster than ever, bringing benefits (and occasional problems) to everyone.

Related Nursing Content:  The Growing Demand for Nurses in a Variety of Roles

The Internet and the expert patient

This is the information age and there is a lot of it out there. Medical knowledge is no longer the arcane dominion of the professional few.

Everyone now has the ability to easily access information about symptoms, conditions, and medications, and other treatments. There is, in fact, an overwhelming amount of medical information on the Internet.

Some of this information is evidence-based and
up to date but a lot of it is absolutely not.

Nurses with direct patient contact, therefore, have an important new aspect to their role. That is to empower patients to locate and learn from reliable, credible sources.[mfn]Finding Credible Medical Information Online. OpenMD. https://openmd.com/guide/finding-credible-medical-sources[/mfn]

Many healthcare professionals are finding that their patients know more than ever about their medical conditions. It is expected that this will continue to increase over time as access to medical information becomes easier and easier.

Many clinicians have found that it can be a very positive experience to work with informed patients and families. This is because it leads to a more equal professional-patient relationship and a more cohesive approach to care and treatment.

Remote healthcare

Advances in technology are already enabling real-time, remote monitoring and investigations. Here are some examples:

  • Medical devices

    • The Implantable Loop Recorder detects heart rhythm disturbances and can relay information to a central monitoring team. This enables diagnoses and, perhaps in the future, immediate emergency responses.
    • Combined continuous blood glucose monitors and insulin delivery systems facilitate optimum diabetes management.
  • Consumer devices

Tracking activity and vital signs has become a part of everyday life for many people. One measure of its popularity is the fact that manufacturers of wearable activity and heart rate trackers.  These include Apple, Samsung, and Fitbit, who are reporting huge profits. Fitbit alone has sold more than 76 million devices.[mfn]https://www.statista.com/statistics/472591/fitbit-devices-sold/[/mfn]

  • Home blood tests

Many of the blood tests traditionally processed in labs can now yield almost instant results with just a finger prick at home. For example, in addition to well-known home tests such as blood glucose and pregnancy tests, people can also do home-testing for cholesterol, prothrombin time for blood thinning, hepatitis C, and some drug tests.

The use of these technologies can influence individual diagnoses and treatment plans. It can also show trends and collect demographic data on a scale greater than ever before.

Less time in clinics and fewer admissions

Remote diagnostic tools mean less time in clinics because results clinicians have ready access to results from these monitors. They can then respond to them via virtual consultations by telephone or online.[mfn]Powell, J. et al. (2009) ‘Pilot study of a virtual diabetes clinic: satisfaction and usability’, Journal of Telemedicine and Telecare, 15(3), pp. 150–152. doi: 10.1258/jtt.2009.003014.[/mfn]

Remote healthcare will never replace the need for an acute hospital setting. However, with quicker diagnosis and treatment in the community, a reduction in unplanned admissions to hospitals can be expected.

Communication technology in the hospital is changing nursing practice

Electronic clinical observations have been rolled out on a massive scale in hospitals around the world. These can take the form of individual patient monitors, which record and store all data that was traditionally recorded on paper. These include regular blood pressure readings, heart rate, respiration rate, and temperature. This data can be accessed by remote hand-held devices carried by the healthcare team.

With built-in protocols for alerting members of the team when results are out of a set range, the right people can converge on a sick patient in seconds.[mfn]Peters M, Moore P (2018) Using quality improvement methodology to implement an electronic pediatric early warning system (PEWS) across Great Ormond Street Children’s Hospital (GOSH) Archives of Disease in Childhood[/mfn] This technology also allows clinicians to prioritize their workload and request assistance from specific services at the push of a button or the tap of a screen.

The use of remote patient monitoring devices in hospitals can mean getting the right help for your patients without even leaving their side.

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Improving safety

Patient safety is always top priority for nurses.

Electronics devices have long been used to improve patient safety. These range from chair sensors to alert staff when a confused or unsteady patient has stood up to wristband barcode scanners to ensure the right medications get to the right patient.

The World Health Organization has long championed the use of emergent technology to improve patient safety [mfn]https://www.who.int/patientsafety/en/brochure_final.pdf[/mfn] For example, electronic reporting of incidents aids in the understanding and prevention both at a local and global demographic level. One study found a 250% decrease in drug errors following the implementation of electronic incident reporting in one hospital.

Is health technology the answer to all our problems?

As always, with such a paradigm shift we are met with bumps along the way. Further, much of the technology we’re using is still in its infancy.

With remote and mobile healthcare, we have a huge increase in the amount of cloud-based and remote data storage of sensitive patient information that is, by necessity, identifiable, accessible, and retrospective.[mfn]Dixon J. F. Going Paperless with Custom-Built Web-based Patient Occurrence Reporting. Joint Commission Journal on Quality Improvement. https://www.ncbi.nlm.nih.gov/pubmed/12101550[/mfn]

Privacy is a concern

Legislation exists across the EU[mfn] Health and Social Care, Information Commissioners Office, UK https://ico.org.uk/for-organisations/in-your-sector/health/[/mfn] and US[mfn]Health Information Privacy, U.S. Department of Health & Human Services https://www.hhs.gov/hipaa/index.html[/mfn] in particular, that aims to govern the use of medical records.  Governing in a way that balances privacy concerns with the sharing of information necessary to prove high-quality care. A robust system for informing patients and gaining consent for any projected use of their information is essential. 

As the public becomes more aware of the cybersecurity and privacy issues faced by organizations that hold large amounts of valuable data, the use of this data will be informed by evolving ethical standards.

Technology and nursing are here to stay

We are undoubtedly in the middle of a technological revolution, nowhere so much as in medicine and nursing. But medical technology is only a tool to make patient care more efficient and effective, to improve safety and speed. 

Robots are not going to replace nurses anytime soon.

One potential benefit of new technologies is that they may eventually free up nursing time for more traditional care and patient-centered activity.

Whatever happens, one thing is clear. Technology is poised to change nursing practice into something that would have been unrecognizable by our predecessors.

The good news for nurses is that some things will never change, Patients and families will always need and want a human touch and a good patient experience.

 

References


[1] Jones, Diana P.; Wolf, Debra M (2010) Shaping the Future of Nursing Education Today Using Distant Education and Technology

[2] Finding Credible Medical Information Online. OpenMD. https://openmd.com/guide/finding-credible-medical-sources 

[3] https://www.statista.com/statistics/472591/fitbit-devices-sold/

[4] Powell, J. et al. (2009) ‘Pilot study of a virtual diabetes clinic: satisfaction and usability’, Journal of Telemedicine and Telecare, 15(3), pp. 150–152. doi: 10.1258/jtt.2009.003014.

[5] Peters M, Moore P (2018) Using quality improvement methodology to implement an electronic paediatric early warning system (PEWS) Across great Ormond Street children’s hospital (GOSH) Archives of Disease in Childhood

[6] https://www.who.int/patientsafety/en/brochure_final.pdf

[7] Dixon J. F. Going Paperless with Custom-Built Web-based Patient Occurrence Reporting. Joint Commission Journal on Quality Improvement. https://www.ncbi.nlm.nih.gov/pubmed/12101550

[8] Health and Social Care, Information Commissioners Office, UK https://ico.org.uk/for-organisations/in-your-sector/health/

[9] Health Information Privacy, U.S. Department of Health & Human Services https://www.hhs.gov/hipaa/index.html

For the vast majority of mothers, childbirth goes normally, naturally, and with few or no complications. However, a recent report of obstetrics liability claims by medical insurer Coverys provides a shocking wake-up call regarding maternal and fetal health risk. Especially as it pertains to the labor and delivery room.

The study analyzed 10,618 closed medical professional obstetrics claims between 2013 and 2017. It found that obstetrics was the 5th most common claim allegation across all categories. Eighty percent of the claims were of high severity. Either the mother, infant, or both, died in 24% of these cases.

Poor management

Perhaps the most disturbing finding from the report was that 40 percent of these obstetrics claims were related to poor management during labor and delivery. The report noted a lack of standardization and clinical training. This poor management was specifically related to fetal heart monitoring as a major factor behind these startling numbers.

Many of the nurses involved in the claims were new to the labor and delivery unit. They had not been fully trained to read electronic fetal monitoring strips. Nor did they understand the importance of acting upon warning signs in a timely manner to prevent red flags from becoming tragedies.

While liability is always a concern in obstetrics, the greatest worry for those of us in the field is that of fetal health and safety, and the safety of their mothers.

A 2011 study found that fetal heart monitoring was associated with a significant decrease in both neonatal morbidity and mortality.

The authors surmised that the reason for this decrease was related to biological factors. These factors were associated with certain fetal heart patterns that precede hypoxia, academia, and death. The use of electronic fetal monitoring allowed for earlier detection of such patterns and thus, timely interventions by obstetric staff.

Continual fetal monitoring

In the United States, continuous fetal monitoring (CFM) has been the standard of care in hospitals nationwide. Clinicians use a doppler fetal monitor on the mother’s abdomen to listen to the heart rate of the fetus and monitor contractions in the woman’s uterus continuously during labor.

Whereas CFM once resulted in a long strip of paper showcasing the infant’s heartbeat, heart rate patterns (“tracings”) are now stored electronically. They are viewed on monitors throughout the unit.

Medical staff can log into a portal to see the tracings for each patient in real-time. This allows them to monitor and intervene quickly should the need arise.

Usually, the fetal heart rate is monitored in coordination with uterine activity, such as contractions, to allow for greater insight into labor.

Clinicians use both pieces of information – fetal heart rate and uterine activity – to interpret the heart rate monitor data and assign a category to the tracing – I, II or III:

  • Category I is normal and does not require intervention
  • Category II is “indeterminate.” It may require some corrective measures throughout the labor, such as changing the mother’s position
  • Category III is considered abnormal and high risk.

If the tracing indicates a category III, the delivery is typically expedited, many times via c-section.

CFM overuse

This has resulted in some controversy around the overuse of CFM among low-risk women and its impact on the number of c-sections that come about as a result of misinterpreting the patterns in the heart rate.

For example, a recent article in Scientific American highlighted this issue, pointing to the fear of litigation among providers as a major factor for the surge in expediting interventions among low-risk mothers, such as:

  • Oxytocin stimulation
  • Forceps deliveries
  • episiotomies
  • C-sections

The report also emphasized that reading the monitor data can be an imprecise science – what appears to be a distress signal for one provider may be interpreted as a normal reading to another.

CFM is the standard of care

While the article points to CFM’s potential for misinterpretation, it simultaneously emphasizes the point that CFM is the standard of care employed by most hospitals.

Therefore, training staff to accurately and systematically interpret findings is critical. The goal should be to make the best decision for the health of the infant and the mother.

This may sometimes mean an expedited delivery is the best course of action. However, the training should also emphasize that in many cases, especially among low-risk women, this is not the only option. 

Training on fetal heart rate monitoring

Right now, regular, repeated training on fetal heart rate monitoring isn’t always mandatory. The requirement is up to the individual hospital.

Ongoing education and training on how to evaluate fetal heart rate patterns are vital to ensure that clinicians interpret fetal heart rate data in a standardized way. Because of that, Ob Hospitalist Group (OBHG) requires our team of more than 700 physicians and midwives nationwide to complete fetal heart rate training every two years.

In addition to this training, our OBHG leadership has mandated even stricter standards when it comes to training test scores. This includes interpretation of the data being shown through fetal heart rate monitoring.

It also includes supplementary measures to determine whether an intervention is needed especially in the case of a patient with category II tracings. This is because it is when the majority of c-sections for non-reassuring fetal heart tones tends to take place.

The American College of Obstetricians and Gynecologists (ACOG) offers a number of electronic fetal monitoring courses that should be on every OB/GYN’s priority list.

The Perinatal Quality Foundation, a non-profit, is dedicated to improving the quality of obstetrical services in the United States. It also provides an electronic fetal monitoring credential for obstetrical nurses, nurse midwives, and obstetricians.

Interpreting the patterns

Interpreting the patterns found in fetal heart rate monitoring and uterine activity depends on an understanding of the language of the data. This allows providers to correctly assign the category it corresponds to and intervene appropriately.

While this can be taught in a number of ways, ongoing training greatly improves the consistency in interpretation among staff. This translates into better outcomes for patients.

Pregnancy-Related Articles:   
How to Minimize the Risk of ASD During Your Pregnancy
3 Best Pregnancy Workouts

The bottom line

Hospitals and physician groups must make sure that labor and delivery staff is properly trained to recognize and respond to fetal monitoring output. This will ensure that quality of care and great patient outcomes are a standard feature of our labor and delivery units.

According to the CDC, each year in the United States, more than 1.5 million Americans will develop sepsis. At least 250,000 Americans will die from sepsis.

The costs of sepsis are staggering

Moreover, it is estimated by the Sepsis Alliance that the costs related to sepsis are about $27 billion annually.

“Sepsis has been named as the most expensive in-patient cost in American hospitals in 2014 averaging more than $18,000 per hospital stay.

With over 1.5 million sepsis hospital stays in 2014 per year, that works out to costs of $27 billion each year. Studies investigating survival have reported slightly different numbers.

However, it appears that on average, approximately 30% of patients diagnosed with severe sepsis do not survive. Up to 50% of survivors suffer from post-sepsis syndrome.”

Although these numbers may be staggering, they may not hit home until sepsis strikes a loved one, a friend, or even yourself.

Dr. Ken Rothfield, Chief Medical Officer, Medical City Dallas 206 x 314

Dr. Ken Rothfield, Chief Medical Officer, Medical City Dallas
Photo supplied by the author

Meeting a sepsis survivor

For me, it struck when Dr. Ken Rothfield and I met at a healthcare conference. Dr. Rothfield is Chief Medical Officer at Medical City Dallas, which is operated by the Hospital Corporation of America.

He is also a member of the advisory board of the Physician-Patient Alliance for Health & Safety (PPAHS), a non-profit advocacy group that I founded more than seven years ago.

He has been a strong advocate for and partner in patient safety. While at the conference, he told me:

I almost died from sepsis.”

It started with a hernia

For Dr. Rothfield, his journey with sepsis started with a decision to finally get his hernia fixed. It was not an emergency visit to the hospital. Rather, it began with a scheduled surgery.

Dr. Rothfield describes how he contracted sepsis:

“In 2002, I found out that I had an inguinal hernia on the morning I was supposed to run the Dublin, Ireland Marathon.

Initially, the hernia was small and easily ignorable, but it started becoming increasingly more uncomfortable.

It was time for surgery.

The surgery was scheduled for the Monday before Thanksgiving in 2015. This would give me a long holiday weekend to recover.

I thought I was going in for a simple procedure. I had no idea it would turn into a life-threatening venture.”

The recovery ended up taking months

Dr. Rothfield continued his story saying,

“The weekend recovery wound up taking months.

One of the staples in the mesh hernia repair fell out after surgery leading to a small section of my small intestine becoming trapped.

I developed terrible pain and abdominal distention.

I was admitted to the hospital at 3 am on Thanksgiving. By Friday, I was septic. I had an overwhelming infection and was critically ill.

Saturday, I had emergency surgery, where they discovered I had a section of gangrenous intestine. That led to a big, open operation.”

I understood the potential worst-case scenario

As an experienced doctor, Dr. Rothfield understood his condition could be fatal. He told me:

“As a doctor with about 25 years’ experience, I understood the potential worst-case-scenario outcomes.

I’ve witnessed enough cases where a patient comes into the hospital with an abdominal catastrophe. Unfortunately, the patient doesn’t make it back home.”

Behind these stark words was this knowledge – the prognosis for sepsis and septic shock is decidedly poor. As Dr. M.H. Schoenberg and his colleagues from the Department of General Surgery, University of Ulm, Germany explain:

“Approximately 10% of patients in the ICU suffer from sepsis, 6% from severe sepsis and 2-3% from septic shock.

SIRS [systemic inflammatory response syndrome] occurs more frequently. Its occurrence ranges from 40% to 70% of all patients admitted to ICUs.

The overall prognosis is still poor despite the recent advances in ICU treatment.

The mortality rate of SIRS ranges from 6% to 7%. In septic shock, it amounts to over 50%.

In particular, abdominal sepsis exhibits the highest mortality rate with 72%. The long-term prognosis is equally poor; only approximately 30% of patients survived the first year after hospital admission.

A doctor and a patient with sepsis

Dr. Rothfield has the unique perspective of experiencing sepsis from the point of view of a doctor and a patient. From these perspectives, he emphasizes the need for early detection and treatment of sepsis.

Based on his knowledge and experience, he implores his fellow clinicians to commit to act quickly and proactively:

“I would like you to commit to early detection and treatment of sepsis.

You may not get a second chance to save your patient’s life.

Early diagnosis of sepsis is critical

“First, you have to know when your patient is suffering from sepsis. You must know at the earliest possible time when sepsis is occurring.

Clinical studies show that mortality is significantly reduced if septic patients are identified at early stages of the disease process.

In my own case, I was admitted on Thursday. By Friday I was septic. But it was not until Saturday that emergency surgery was performed which removed a section of gangrenous intestine. 

In my opinion, early diagnosis can best be achieved through patient monitoring. Such monitoring would have been able to provide early detection of my sepsis. I could have had an earlier intervention.”

How monitoring can help 

“Monitoring a patient’s heart rate and respiratory rate allows clinicians to detect changes over time while supporting hospital protocols for early detection of sepsis.

Although nursing assessments taken every few hours may detect sepsis, patient monitoring can alert you at the earliest possible moment when sepsis is developing.

“Remember, You may not get a second chance to save your patient’s life – monitor for sepsis.”

Dr. Rothfield also recommends:

  • Treat Sepsis Early 

Clinicians are scientists at heart. They want to know exactly what they are treating. A delay in treatment while waiting for a definitive diagnosis could be fatal to the patient.

“Clinicians should be open to the idea that treatment needs to start immediately, without necessarily knowing the source of the infection.”

  • Work Collaboratively 

Although much lip service is given to creating a culture of safety, we need to ensure that effective care is the first priority.

Dr. Rothfield says,

“Lead your team in developing and maintaining a safety culture. If you are a leader at a hospital like I am, or a leader of a unit in a hospital, I ask you to lead your team in developing and maintaining a safety culture.”

  • Be Open to Using New Technology 

Use technology as an enabler for better patient care.

“The use of medical devices and information technologies can improve care. Be open to using new technology to improve the reliability of this process.”

Watch the video, to learn about some examples of these new technologies.

Useful resources:

For more information and resources on sepsis, please go to www.sepsis.org or www.global-sepsis-alliance.org.

PPAHS is proud to be a member of the Sepsis Alliance and the Global Sepsis Alliance.

The bottom line

  1. Post-operative sepsis is a serious, potentially fatal complication of surgery 
  2. Sepsis can progress rapidly
  3. Sepsis can be fatal even with aggressive treatment
  4. Early diagnosis is crucial
  5. Bedside vital sign checks by nurses are not enough, continuous patient monitoring provides real-time data.
  6. Monitor heart rate and respiratory rate, looking for changes over time. It can be critical for early diagnosis

Please join Dr. Rothfield in proactively monitoring for sepsis so that early treatment can be initiated.

You may not get a second chance to save a patient’s life!

Most of us don’t think twice about getting on a commercial airline. The odds of dying on even the worst 39 airlines is 1 in 1.5 million or a .0000006% chance of death. This is more than five times better than Six Sigma quality (defect levels below 3.4 per million).

In a 2012 study published by The Lancet, mortality rates for surgery, up to two months post care, are 3.6%. Obviously, this is far from Six Sigma quality. Meanwhile, surgery volumes and outcome data are not publicly available to study.

Global tracking procedures

Remember the Malaysian Air Flight 370 that disappeared March 2014 killing 239 people? The global airline industry responded by augmenting global tracking procedures improved to mitigate similar future tragedies.

This is an example of an industry learning from failure and applying new standards to improve outcomes.  We can learn something here.

Tracking time to fail

A friend mine called to offer a sunset test ride in a Learjet 45. He’s the Captain for Caterpillar Aviation with over 14,000 hours flying all types of aircraft – even acrobatics. This is a hot rod of an airplane. It can do zero to rotate in only a few seconds and is capable of 535 MPH or 81% the speed of sound.

Earlier that week, a pre-flight check identified a warning indicator. The landing gear and back-up aileron hydraulics showed a pending failure in 20 operational hours.

The Learjet has an information system so thorough, connected, and well programmed that it tracks the time to failure for all critical flight systems based on historical failure. The flight crew is alerted when components are due for replacement before they actually fail – which could be in flight.

Bombardier, the manufacturers of the Learjet, collected data and programmed what it learned about critical failures in systems. They have also created a live indicator. Their goal was to have a great outcome: flight safety.

A critical failure live indicator

In this case, the parts were inexpensive brushes in a motor that drives a hydraulic pump. Sometimes the smallest things, combined with experience, have the potential for a large impact on quality.

Standard FAA quality procedures mandate that following maintenance on critical systems, a non-commercial test flight must be made. The fuel for the test flight costs more than the brushes. But the ride at sunset was a beautiful thing – lucky me!

Just like the flight system algorithms and indicators removed the impractical work of checking brushes before each flight, well-programmed healthcare algorithms, starting with structured historical data can do the same. An oncology project proved it. I’ll get to that in a bit, but first, more about data.

Time to fail: What healthcare can learn from airplanes

Have you ever heard of dirty data? In a paper published by Datamark, analysts from Merrill Lynch, Gartner and IBM agreed that between 60% and 80% of health data is unstructured.

It is referred to as “dirty data” meaning it’s not in a defined field like name, address, city, state or zip. Unlike defined fields, unstructured data cannot be easily sorted and mined. It includes physician notes and impressions, a paragraph in the EMR from the nurse, or even an image.

In addition, data in healthcare are not interoperable or translatable between systems.  Unfortunately, not much interfaces with much else. Instead, there are disparate, unconnected systems and uncommon languages.

Natural language processing

Natural language processing (or NLP) technology interprets spoken or written language. The limitation lies in its inability to semantically distinguish true meaning or lexicon.

For example, words might say “this is the third time I ordered this meal.”  Does that mean you were so pleased in the past you came back and ordered the same thing two more times? Or, does it mean you’ve placed your order three times and still don’t have it? 

Advancing to natural language understanding or NLU is the next step to contextual, semantic understanding of unstructured data. Development is underway in companies like Digital Reasoning and Cicayda who analyze e-documentation in legal reviews and discovery.

Progress Using Defined Data

Working with a very large oncology group, my company studied drug utilization appropriateness against patient outcomes. We looked at about 300,000 encounters over 2 years.

The lead oncologist, who is both brilliant and humble, wanted to know what was going to happen to patients before they treated them. Looking at the impact of oncology drugs was a great place to start.

Using defined non-Personal Health (Patient) Information (PHI), prescription orders from four different EMR systems and lab results, we programmed the EMR detail data against drug manufacturer’s guidelines.

Failure to follow guidelines

Forty-one percent of the time, drug utilization fell outside guidelines, including

  • too much drug used,
  • not enough drug used
  • drugs prescribed with the wrong timing.

The impact on patients, measured through outcomes (e.g. blood work) revealed the result. The financial impact of inappropriate use was easier to score at $16 million.

Failure analytics and the future of healthcare

The algorithm for the oncology equation worked. It consolidated the collective training and experience of physicians and scientists encapsulated in one place making for easy reference and guidance against real data from disparate systems.

This is the first step toward an automated indicator of future quality, using historical outcomes to guide treatment decisions.

In a directionally similar step, Medicare has mandated medical imaging begin using Clinical Decision Support tools January 1, 2021.

This mechanism uses past treatment efficacy to advise clinicians to the most appropriate procedure. While it uses static unconnected data, it’s a good start. It provides guidance to help those busy ER docs order the right exam.

Let the evidence guide us

We must transform practice (try this) into science (know).

Health data challenges are complex but can be overcome with planning, communication, and strategy.

Processes and standards should be driven by evidence and outcomes” 

This is the direction in which we need to be pointed. 

Let’s start by using consolidated historical data from clinical information (not just claims data) combined with the collective experience of clinicians to inform better clinical decisions and not just create post-encounter reports.

Augmented intelligence is needed

Capable technology that can accept disparate defined data is proven. More complex, but also proven is capturing the subject matter expertise of clinicians in algorithms.

Combining data and automating functions can produce active, stratified, evidence-driven guidance. No artificial intelligence here.

Augmented Intelligence, rather than artificial intelligence, is a more accurate representation. It distills the details of every encounter, treatment, and outcome to guide future treatment. It does this by consolidating the experiences of many and sharing it as universal guidance easily stratified by user preference. This approach will drive quality outcomes and value.

Honeybees

A bee swarm is a force to be reckoned with. Working in the yard the day after my ride in the hot rod Learjet ride, I enjoyed the full wrath of one.

After the fired-up little bees got under my clothes, they succeeded in stinging me in all sorts of unimaginable locations. It was a display of amazing coordination.

I’m lucky I don’t have an allergy to bee stings and am thankful for 100mg of Benadryl. The point is that the smallest things, when coordinated with great communication, can have a fierce impact on change.

These small creatures are a great illustration of the power of aligned goals with common communications and a strategy, producing an effective force that drives away perceived danger.

The bottom line

The current trajectory of healthcare indicates that we will miss our flight safety targets if we don’t get to work…starting with the small things. While public transparency and automated clinical risk indicators from common data remain elusive, the good news is, progress is taking place, albeit often in silos.

Please comment below or drop me a line at [email protected] I’d love to hear your ideas and progress.

Digital distraction in healthcare is emerging as a great threat to patient safety and physician well-being.[1] This phenomenon involves the habitual use of personal electronic devices by healthcare providers for nonclinical purposes during appointments and procedures.[2] Some call it “distracted doctoring.” Matt Richtel, a journalist for the New York Times who won a Pulitzer Prize for his work on distracted driving, coined the term “distracted doctoring” in 2011. [3] Like driving, attending to a patient’s complex care needs is a high-risk activity that requires undivided attention and presence in the moment to ensure the safety and protection of others.

But the threat might more aptly be called “distracted practice,” as it impacts all healthcare workers and staff. While distraction is particularly concerning in the operating room, emergency room, and critical care areas, it can impact all healthcare settings—including the office practice. Personal electronic devices can create a digital distraction so engaging that it consumes awareness, potentially preventing healthcare providers from focusing on the primary task at hand—caring for and interacting with patients. And the consequences can be devastating.

Our Devices Are Addictive

In today’s electronic culture, it has become unthinkable to be without personal electronic devices. Growing evidence shows that our personal electronic devices and social media are addictive.[4] The reason is dopamine. Our dopamine systems are stimulated by the unpredictable, small, incomplete bursts of information with visual or auditory cues. For example, we are never quite sure when we will receive a text message and from whom. We may keep checking to see who liked our recent Facebook post. And when our devices ding or vibrate, we know our reward is coming. Yet as when gambling or playing the lottery, the anticipation of the reward is (usually) better than the reward itself. This results in more and more of what some call “seeking” and “wanting” behaviors. Then instant gratification encourages dopamine looping, and it becomes harder and harder to stop the cycle.

Distraction can also be both a symptom of and a contributor to healthcare provider stress and burnout. As a symptom of burnout, digital distraction is a way to escape a stressful environment. As a contributor to burnout, digital distraction impedes human interaction because of the sheer volume of data-demanding our attention.

Medical Malpractice Implications

For most healthcare providers, distractions and interruptions are considered part of the job; it is the nature of their work. If we consider healthcare distraction on a continuum, on one end are distractions related to clinical care (e.g., answering team member questions or responding to surgical equipment alarms). On the other end of the continuum are distractions unrelated to clinical care (e.g., making personal phone calls, sending personal text messages, checking social media sites, playing games, or searching airline flights).

From a litigation perspective, the distinction between distractions related to clinical care and those unrelated to clinical care is important. In a medical malpractice claim where there is an allegation that an adverse event was caused by distracted practice, a distraction caused by a clinical-care-related activity may be found to be within the standard of care and is, therefore, often defensible. But where it can be shown that the distraction was caused by non-patient matters, the plaintiff’s attorney will certainly use that against the defendant. In these situations, the defendant’s medical care may not even enter the equation, because during eDiscovery the metadata (i.e., cell phone records, scouring findings from hard drives) serves as the “expert witness.” Even if the defendant’s clinical care was within the standard, the fact that there are cell phone records indicating that the healthcare provider was surfing the Internet or checking personal e-mail may imply distraction and could potentially supersede all other evidence.

Preventing Distractions

Complex problems require a multifaceted approach. Organizations, teams, and individuals all should take responsibility and ownership for reducing the risks associated with digital distraction. The following are risk management strategies to prevent distractions and enhance patient safety.

Organizations

  • Create awareness

    • Recognize the extent of the problem and risks.
    • Model appropriate personal electronic device use behaviors.
    • Tier communication to batch non-emergent messages.
    • Refrain from sending texts on non-urgent matters.
    • Do not expect immediate responses for non-urgent matters.
  • Educate system-wide

    • Train all healthcare providers and staff at orientation and conduct annual refreshers on safety concerns, legal risks of using personal electronic devices when providing care, device-user etiquette, and the addictive potential of technology.
    • Use simulation-based learning where distractions and interruptions are introduced during high-risk procedures.
    • Use case studies of real-life examples where distraction was alleged to play a role in an adverse event.
  • Deploy technology solutions

    • Manage facility-issued devices.
    • Create technology-free zones.
    • Limit Internet access to work-related sites only—EMR, labs, images, pharmacy formulary, state Rx databases, and decision support/cognitive aids.
  • Enforce

    • Monitor compliance with system-wide protocols and guidelines.
    • Clearly define how personal electronic devices are used in patient care areas.

Teams

  • Reinforce situational awareness and mindful practices with your team or department through:
    • Unit-specific protocols: “Sterile Cockpit” and “Below 10,000 Feet” protocols limiting or eliminating non-essential activities during critical phases of procedures and high-risk activities.
    • Empowering every team member to speak up when they have a safety concern. For example, encourage team members to speak up when they notice another member is so focused on a personal electronic device that he or she has lost situational awareness about the patient’s clinical condition.
    • Applying TeamSTEPPS® principles: leadership, situational awareness, mutual support, and communication.
  • Create a process where employees can be reached via a call to a central location, with messages relayed to the employee by a staff member. This alleviates employees’ desire to have their personal electronic devices nearby in case of a family emergency.
  • Monitor compliance as part of the team’s quality measures.

Individuals

  • Take personal responsibility—ignore distractions, especially during high-risk procedures, and make sure to speak up, set an example, and remain vigilant.
  • Practice situational awareness:
    • Pay attention to what is happening in the present moment.
    • Increase attention, focus, and concentration.
    • Leave your device behind.

New CME Courses Address Distracted Practice Concerns

Two new CME courses from The Doctors Company, How Healthcare Leaders Can Reduce Risks of Distracted Practice in Their Organization and The Risks of Distracted Practice in the Perioperative Area, address addiction to personal electronic devices and provide strategies that individuals and organizations can use to minimize the patient safety risks associated with distractions from these devices.

Find these courses and explore our extensive catalog of complimentary CME and CE activities at httpss://www.thedoctors.com/patient-safety/education-and-cme/ondemand/.

Works Cited
________________________________________

[1]Distracted Doctoring: Returning to Patient-Centered Care in the Digital Age https://www.amazon.com/Distracted-Doctoring-Returning-Patient-Centered-Digital/dp/331948706
[2] Treat, Don’t Tweet: The Dangerous Rise of Social Media in the Operating Room https://psmag.com/social-justice/treat-dont-tweet-dangerous-rise-social-media-operating-room-79061
[3] As Doctors Use More Devices, Potential for Distraction Grows httpss://www.nytimes.com/2011/12/15/health/as-doctors-use-more-devices-potential-for-distraction-grows.html
[4] Why We’re All Addicted to Texts, Twitter and Google https://www.psychologytoday.com/blog/brain-wise/201209/why-were-all-addicted-texts-twitter-and-google

Additional Resources
_____________________________

  1. Daily Time Spent on Social Networking by Internet Users Worldwide from 2012 to 2017 (in minutes) https://www.statista.com/statistics/433871/daily-social-media-usage-worldwide/
  2. Anesthesia and the Law, Preferred Physicians Medical Risk Management Newsletter (August 2014, Issue 39)https://www.ppmrrg.com/risk-management/anesthesia-law/archive
  3. Interruptions and Distractions in Health Care: Improved Safety with Mindfulness https://psnet.ahrq.gov/perspectives/perspective/152/interruptions-and-distractions-in-health-care-improved-safety-with-mindfulness
  4. Distracted Doctoring: The Role of Personal Electronic Devices in the Operating Room https://www.sciencedirect.com/science/article/pii/S2405603017300365

The Doctor Company

Contributed by The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

This post was sponsored by The Doctors Company, the nation’s largest physician-owned medical malpractice insurer.

When I was a medical student, some of my free-clinic patients died of treatable conditions. The clinic was in Southeast Texas, near Houston. Patients would drive in from an area covering more than 200 miles along the coast. The broad reach of the St. Vincent’s Student-Run Free Clinic was a testament to how bad access to care really is in rural Texas: Imagine being so desperate for medical care that you drive four hours round-trip to be cared for primarily by medical students.

St. Vincent’s was a wonderful place to train, but all too often it left me brokenhearted. We could diagnose patients with cancer, but couldn’t get them accepted to local hospitals for the surgery and chemo they needed. And so, they would die.

If we had a big sack of money

My mentor Susan McCammon taught me how to tell a person that she is going to die for lack of care. You say something like this:

“If we had a big sack of money, here is what care would look like. There would be surgery, radiation, chemo, and all the side effects of that. And on average, you’d have an 80% chance of being alive five years from now. Now, without that, there are some medicines we can give. And we can control your pain. And we can keep on pushing for a hospital to take you. But if that doesn’t happen—and it may not happen—then you probably will not survive this year.”

Susan learned this conversation well because, as a head-and-neck cancer surgeon, she refused to abandon her patients after they were abruptly kicked off the rolls of our hospital’s charity care program. In fact, Susan saw her patients through—many of them to death—and became a palliative care physician as well as a surgeon. She learned well how to tell patients they will die for lack of access to care, and she was able to teach me.

Those conversations, however, are not something she would ever have wished on her students. They are not pretty. They are not what one expects to learn in medical school.

Student-run clinics – the places of last resort

My fear, as Congress debates the American Health Care Act (AHCA), is the same fear the American Medical Association has: Under the AHCA, millions more Americans will lose insurance coverage.

This means that the next generation of medical students will not be spared the heartbreak my classmates and I experienced. According to a 2014 study, student-run free clinics are proliferating: More than 75% of medical schools have such a clinic, and more than 50% of students train in these clinics.

In student-run clinics that are embedded in communities with robust safety nets, students can refer patients out when they need tertiary care. But in many student-run clinics—particularly in the 19 states that did not expand Medicaid under the Affordable Care Act—student-run free clinics are places of last resort.

My friend and fellow St. Vincent’s volunteer, Jacob, began medical school under the impression that there was a safety net. “I didn’t realize that we were the safety net,” he said.

No apparent distress

My book, No Apparent Distress: A Doctor’s Coming-of-Age on the Front Lines of American Medicine, relates the true stories of the students, doctors, and patients at St. Vincent’s and the other places where I was privileged to train: Texas prison hospitals, public hospitals, and a border clinic where patients would wade across the Rio Grande to see a volunteer doctor.

I also tell the healthcare stories of my own family. In part because I’m a carpenter’s daughter from a small town in Texas, my uninsured patients never felt scary or foreign; they felt like family. My brother, a commercial fisherman, has been uninsured for most of his adult life.

Because the book is aimed at a general audience, the broader argument it makes is about general folks—how medical students and residents train on the poor. I hope that readers will begin to reckon with the notion that we, as a society, owe something to the folks who have served as subjects of medical training. Just as the historian Harriet Washington exposed how medical research relies disproportionately on the use of black bodies in her book Medical Apartheid,

I ask readers to consider the ways that medical training relies disproportionately on the use of poor communities and communities of color.1

Learning on the poor

Indeed, one of the reasons I wrote the book was because I had become increasingly distressed by the ways that I, as a student, benefited from the unequal distribution of medical resources. As a student, I did things to my uninsured patients—endometrial biopsies, minor surgeries, the delivery of diagnoses of cancer—that I would never have been allowed to do to an insured patient. I learned good skills because I was allowed to practice on people who had no other option.

My experience was not unique. As researchers Smith et. al. note in their study, one of the two greatest strengths of free clinics perceived by volunteers is “student education.”2

Nor is this experience new. In his book, The Social Transformation of American Medicine, the historian Paul Starr describes how American teaching hospitals were deliberately built in centers of urban poverty so that students would have access to poor patients.3 And just as free clinics proliferate today, students and residents continue to flock to international rotations: Donating our much-needed skills to—and learning our skills from—the poor of the world.

We do this work out of a deep dedication to social justice, and out of a commitment to the health of our neighbors. We do it out of love. My teachers in academic medicine, many of whom have dedicated their lives to serving the most medically vulnerable communities, are heroes to me and to the communities they serve.

Trainees benefit directly from denial of care

But because we trainees also benefit directly from the denial of comprehensive care to large swaths of American society, the situation is morally complex. The physician-researcher Merle Lenihan describes charity as a “moral safety valve”—

something that allows providers to feel good about ourselves even as we work within, and benefit from, a deeply unfair system.4

I believe that society should respond to this situation by systematically ensuring comprehensive access to care for all people—that is, going the opposite way of the proposed American Health Care Act.

We physicians must also respond to the honest acknowledgment that we have learned our skills on the poor. We cannot and should not abandon our efforts—any safety net, as I am often reminded, is better than none. But we must testify on behalf of our patients, particularly those too ill or too disenfranchised to speak out and be heard.

Charity is critical. But charity is not enough.

Charity is critical. But charity is not enough. Because most physicians do not own the medicines, operating rooms, and infusion centers that our care requires, there are life- and death-defining limits to what our charity can do.

As I have so heartbreakingly learned, charity cannot guarantee life-saving care when it is needed. Physicians—particularly those of us who work in the safety net—must continue to demand more for our patients than charity alone can offer.


References

1. Harriet A. Washington, Medical Apartheid: The Dark History of Experimentation on American Blacks from Colonial Times to the Presents (New York: Penguin Random House, 2008).
2. Smith S, Thomas R, Cruz M, Griggs R, Moscato B, Ferrara A. Presence and Characteristics of Student-Run Free Clinics in Medical Schools. JAMA. 2014;312(22):2407-2410. doi:10.1001/jama.2014.16066
3. Paul Starr, The Social Transformation of American Medicine. (New York: Basic Books, 1982) 171-172.
4. Merle Sharber Lenihan, Charity in Health Care: Safety Net or (Moral) Safety Valve? (dissertation: University of Texas Medical Branch, 2013).

Editor note: This story was originally published 5/21/2017, this post is republished as a court in Texas takes up a Trump administration supported case to decide an important provision in the ACA, such as pre-existing conditions, is unconstitutional. To better understand the administration’s arguments, please read: How to Kill Pre-Existing Conditions Protections