Archive for December 2011

The Crash of Air France 447: Lessons for Patient Safety

From the start of the patient safety movement, the field of commercial aviation has been our true north, and rightly so. God willing, 2011 will go down tomorrow as yet another year in which none of the 10 million trips flown by US commercial airlines ended in a fatal crash. In the galaxy of so-called “high reliability organizations,” none shines as brightly as aviation. How do the airlines achieve this miraculous record? The answer: a mix of dazzling technology, highly trained personnel, widespread standardization, rigorous use of checklists, strict work-hours regulations, and well functioning systems designed to help the cockpit crew and the industry learn from errors and near misses. In healthcare, we’ve made some progress in replicating these practices. Thousands of caregivers have been schooled in aviation-style crew resource management, learning to communicate more clearly in crises and tamp down overly steep hierarchies. Many have also gone through simulation…

LMWH vs stockings neutral on all-cause mortality and major bleeding

In this large randomized trial of high risk hospitalized patients (eg >age 40 with CHF, cancer, or infection with at least 1 other risk factor for VTE), all cause mortality and major bleeding were no different between those receiving LMWH (40 qday) versus graduated compression stockings. Although this study was not designed to evaluate rate of asymptomatic or symptomatic VTE, there was only 1 fatal PE in each group. The caveats are that this international population had lower risk of VTE than past US study populations (lower rate of a past history of VTE, lower BMI), but nonetheless, mortality and bleeding did not differ between LMWH and stockings in these population of hospitalized medical patients (abstract)

PPIs overprescribed in hospitalized patients

In this administrative database and chart review, ~half of medicine inpatients on PPIs did not have a valid indication. Ongoing overuse of PPIs in the hospital setting continues, and widespread efforts to curb this overuse is needed (abstract)

Saying “No” While Being NICE

A wise man once quipped that saying that we may need to ration healthcare is like saying that we may need to respect the laws of gravity. In other words, when societies have more healthcare needs and wants than resources (and all societies do), rationing is inevitable. The question of how to ration used to be the stuff of academic parlor discussions between health policy wonks and ethicists. But it now occupies center stage in the schoolyard brawl that passes for political discourse in today's America. Exhibit A, of course, was Sarah Palin's fear-mongering over “Death Panels.” Exhibit B: the Right's christening of Don Berwick as "Rationer-in-Chief" (and a communist, for good measure) because he had once expressed his admiration for the British National Health Service. At IHI last week, a newly unplugged Berwick -- fresh from his resignation as Medicare chief -- spoke passionately of solving our healthcare cost…

Modified RASS to detect inpatient delirium

In this small study of 95 hospitalized elders at the VA, researchers validated a modified RASS screening tool to detect delirium. Patients underwent daily screening with the modified RASS and with a comprehensive assessment for delirium by a geriatric expert. The sensitivity and specificity for delirium as a single assessment was 64% and 93% respectively; but if performed daily, the sensitivity and specificity to detect incident delirium was 85% and 92% respectively. This may be a promising quick tool to screen serially for incident delirium in hospitalized patients, but performs less well as a single assessment (abstract)