As we move on to our next project “Using data to improve medicine adherence in children”, we look at why children with ADHD do not take their medicine. We have talked to many professionals (a counselor, a former teacher, a district nurse) and have learned so much. We are going to update the blog about what we have learned from the professionals that we have talked to and will talk to next week.
In my English class, we have to do a project on an NGO (Non-Governmental Organization). I chose the IDSA (Infectious Diseases Society of America) as my NGO and my issue is Bioterrorism. As part of the project, I have to create three products, so I chose social media. It would be greatly apprectiated if you followed and liked my products! Thanks!
Facebook: Bioterrorism Education
Yesterday we had the very exciting opportunity to speak with Mr. Paul Levy, former CEO of Beth Israel Deaconess Medical Center in Boston. We had emailed him asking if he would answer some questions about medical errors and what his take was on how to fix them. He gladly accepted our invitation. We had originally asked him to answer the questions via Skype, but we had technical difficulties so we had to do an old-fashioned conference call. Mr. Levy was very knowledgeable about medical errors, and he had some very insightful ideas on how to fix medical errors that are happening all over the world.
Since Mr. Levy had created a safe environment for his employees that made them feel comfortable reporting their medical mistakes they had made, we decided to ask him what he had done to create that safe environment. He went on to say that when someone comes up to an authoritative figure in a healthcare setting and tells them what they have done, the first natural human reaction of that authoritative figure (whether it be a doctor, another nurse, or even CEO of the hospital) is to blame someone, when it really should be to take ownership of the problem in order to fix it. As he said, "Be hard on the problem and soft on the people.". We cannot fix errors if we do not take ownership of our mistakes.
Hospitals are protective of their clinical data. Hospitals "...don't want to report their clinical data because it might be embarrassing," As Mr. Levy puts it, "When in fact it is not embarrassing at all." Mr. Levy also says that doctors are trained not to make mistakes, but in reality making mistakes will happen to them some time in their career, that's why medical error is also called "human error"- because it will happen to humans sometime in their career. If you don't make mistakes, you are not human. So when they do make mistakes, doctors are scared to report them because 'do not make mistakes' is ingrained into their brains from the first day they walk into medical school.
Mr. Levy also quoted Dave Mayer (with MedStar health) as saying "Educate the young and regulate the old". This means to teach the young that it is okay to make mistakes, while just putting regulations and rules on the older healthcare professionals as they do not know any better that it is okay to make mistakes as well, as they will make mistakes but would still be leery of telling someone because they were taught not to make mistakes.
In order to fix our mistakes, we need "Real-time data", as Mr. Levy said. If hospitals do report their data, Medicare and the insurance companies all go through a 'churning process' to process all the data, which takes two years to do. So when the data comes back, it is two years old and at that point is useless. To quote Mr. Levy, "Old data is useless.". So in order to even get a start on fixing medical errors, hospitals need to understand that reporting their data is not embarrassing. But Mr. Levy had a solution- each hospital would have their own website on the main Medicare website to report data on. They would even have their own passwords. But that idea went nowhere, due to the fact that hospitals are scared to make their data public, as they think it would be embarrassing. But as Mr. Levy puts it, sharing their data is not embarrassing. Cutting down on medical errors is something that needs to happen now- before we reach a point of no return.
The conversation with Mr. Levy was very rewarding, as we gained a wealth of knowledge talking to him. We learned about his solutions to fix medical errors, and we also learned hospitals don't want to share their clinical data for fear of embarrassment. We need to do something about this. We can no longer just sit by and watch medical errors happen and happen again, because it is killing patients that aren't supposed to die every day. We need to get a head start on fixing medical errors. Start in medical schools and teach the students that it is okay to make mistakes, so hopefully that way when the younger generation takes the lead in helping patients, they know it is in fact okay to make mistakes, and that they shouldn't be afraid of reporting their errors to an authoritative figure, or even a peer.
To visit Mr. Levy's blog, please visit http://runningahospital.blogspot.com/
Last week we had the opportunity to speak to the Nurse Manager from our local hospital. She talked to us about the Joint Commission (JC) and the role the commission plays in patient and hospital safety. According to their website, "The Joint Commission survey process is data-driven, patient-centered and focused on evaluating actual care processes. The objectives of the survey are not only to evaluate the organization, but to provide education and “good practice” guidance that will help staff continually improve the organization’s performance.". This means that when the JC surveys hospitals, they look at data from patient charts (collected by health professionals) about what care is given to patients, such as tests being ordered, who the patient's nurse is and how the patient is doing overall. The health professional then goes and enters the collected data into computers or systems such as Electronic Medical Records to help track what care is given to patients, and in turn relays patient information and care processes to other nurses and doctors to minimize communication errors and breakdowns between healthcare professionals, as communication errors/breakdowns can cause medical errors. The Joint Commission then collects the entered data to review for their accreditation process.The surveyors also survey patients on their feelings about the level of care quality they are receiving, and actually observe how doctors and nurses practice care in everyday healthcare situations. If good notes, good patient care and good healthcare processes are noted by the Joint Commission upon review, the hospital is more likely to become accredited by the JC. To be an accredited hospital by the Joint Commission, the surveyors must deem it safe for patients and make sure that care is always improving in the hospital.
Being safe is something all hospitals strive for. The accreditation from the JC is a sign that the hospital is safe and care within the hospital is improving constantly, and also serves as a 'badge' that the hospital is working on reducing the number, severity and frequency of medical errors. The visit from the Nurse Manager was very positive, as it made us feel that professionals in hospitals (even in local areas) are all doing something to try and make medical error a thing of the past.
For more information on the Joint Commission, what they do and how hospitals become accredited, please visit: http://www.jointcommission.org/
Alex and Paige are high school students in a Health Science Informatics Career Pathway. The project we are covering is titled, "To Err is Human." We have discovered the world-wide problem (with a focus on the number of errors that occur in the United States) of uninentional medical errors. From a perspective of a teenage mind, we find it concerning that medical professionals "keep silent" about the errors that occur. Through our initial research, we wish to provide a safe place with this blog where individuals can tell their story about a medical error that has happened to a family member or to him/her. We are not associated with any orgainiziation and do not represent any healthcare entity.
Medical Error is defined as "Medical errors are mistakes in health care that could have been prevented." (What Are) Medical errors are a serious threat to society and healthcare. Examples of errors are operating on the wrong body part, allergic reactions to drugs, leaving surgical instruments in patients bodies, and even death. This is a very serious WORLDWIDE problem and it needs to be fixed immediatley, but we cannot do so until medical professionals talk about their mistakes.
Definition source: Prevent Medical Errors-What Are Medical Errors? (n.d.). Retrieved January 27, 2015, from http://www.webmd.com/a-to-z-guides/work-in-partnership-with-your-health-professional-to-prevent-medical-errors-what-are-medical
Picture Source: http://wwwadventureswendy.blogspot.com/2010_05_01_archive.html