Archive for February 2008

The Checklist Saga: Victory!

I must admit, I didn’t hold out high hopes that a ragtag band of committed clinicians and other quality improvers could change federal policy. But we’ve done just that. If the Feds are capable of rectifying this mistake, who knows what might be next! For those unfamiliar with the Hopkins-Michigan-OHRP checklist story, it is described on my prior blogs here and here. Through it all, our concern has not been just with one ICU safety study (notwithstanding its importance), but with the ruling’s chilling effect on quality improvement and safety activities in healthcare everywhere. Starting with a powerful op-ed in the NY Times by Atul Gawande, and followed by protests that began with this blog but spread like wildfire, pressure began to mount on the OHRP to remove their bureaucratic straightjacket on the field of quality improvement. And yesterday, a consortium of hospital-based medical societies (led by the Society of…

Time to Write Congress re: The Checklist Debacle

Thanks to all of you who have taken the time to write, blog, and rant about the OHRP's horrific decision to shut down the Hopkins-Michigan ICU checklist study, a decision that threatens the future of quality improvement and safety efforts in American healthcare. Today, the major hospital-based societies – representing over 100,000 clinicians and leaders – sent a powerful letter to HHS Secretary Leavitt, asking that he stop the madness. (For background info on this case of massive regulatory hyperplasia, see my prior blogs here and here.)The letter, co-signed by the Society of Hospital Medicine, the Society of Critical Care Medicine, the American Thoracic Society, the American Association of Critical Care Nurses, and the American College of Chest Physicians, is here. And by clicking here, you'll be taken to SHM's spiffy Legislative Action Center, which makes it easy to write to your Senator and Representative. I'm betting that the OHRP…

Is Medicare’s “No Pay for Errors” Plan a Good Idea?

In this month’s issue of the Joint Commission Journal of Quality and Patient Safety, I (with UCSF’s Adams Dudley and the American Hospital Association's Nancy Foster) tackle this provocative question. The answer may surprise you: yes (probably). The devil will be in the details.I hope you’ll have a chance to read the full article (the Joint Commission Journal has made it freely available to readers of AHRQ Patient Safety Network, so you can get it here). But the bottom line is this: in our judgment, a policy of withholding payment for adverse events is reasonable when the following criteria are satisfied:Evidence demonstrates that the adverse events in question can largely be prevented by widespread adoption of achievable practices.The events can be measured accurately, in a way that is auditable.The events resulted in clinically significant patient harm.It is possible, through chart review, to differentiate adverse events that began in the hospital…

Can Medical Errors Be Funny? You Betcha.

All medical mistakes are problematic. A few are truly tragic. But every now and then, a medical error comes along that is downright hilarious. From AHRQ WebM&M, the case-based Web journal I edit for the federal government, here are two of the latter kind. They are a hoot.We published the first about three years ago and called it “Allergy to Holter”:A 52-year-old man was admitted for palpitations and chest pain. As part of the evaluation, on hospital day 4 the patient was sent to the cardiac clinic to start a continuous recording of his electrocardiogram via Holter monitor.Since the patient was ambulatory and had gone for other tests on his own, he was told to go to the cardiology clinic for a check-up of his heart rhythm. He was handed a "Request for Consultation" form, on which there was only one word: "Holter." The form did not state the patient's…