Archive for October 2013

Pressure ulcer reporting not valid

This large analysis compared coded data and data from prevalence surveys; it found coded data overall significantly underreported the rate of hospital acquired pressure ulcers, compared to prevalence surveys, but the data was so variable that some hospitals performed better on prevalence surveys and some performed better on coded data. This study questions the validity of using coded hospital acquired pressure ulcer data for public reporting and value based purchasing (abstract).

Lights, Camera, Action… In Healthcare

About eight years ago I was desperate to improve my golf game. I just couldn’t straighten out my drives or hit my irons crisply. (Yes, I’m fully aware that this is a First World problem). I decided to try golf camp in Palm Springs for a few days. My sensei, a crusty ex-touring pro named Artie McNickle, watched me hit several dozen balls on the driving range, video recorder running. “So, did you figure it out?” I asked with hint of sarcasm after my last shot. I thought I was a hard case. “Sure.” “How long did it take you?” I asked. “One or two swings. But you looked like you were having a good time, so I didn’t have the heart to stop you.” Artie patiently told me what I was doing wrong. Though it made sense in theory, when I tried to follow his directions, I didn’t get…

Regulation: the face-to-face lesson

Regulation always seems like a good idea when the other person has to comply. I know a lot about healthcare, but no so much about energy, education, or food service. Despite my knowledge gap, if a rule goes into effect requiring an individual or company to reduce carbon emissions, add classroom time, or post calorie data, who am I to complain. Someone thought the regulation through, vetted the perspectives of all constituents, and weighed the benefits and harms. Most of us will live a bit better or safer due to the efforts of well-intended public officials. Right? When you begin to pay attention to your patch however, you realize the gripes you have about your regulations (because bureaucrats only scrutinize me) differ little from others as they confront theirs. Your perspective expands and allows for a more measured stance when you say, encounter proposals in the papers or journals. You begin…

Diagnostic Errors: Central to Patient Safety, Yet Still In the Periphery of Safety’s Radar Screen

In 2008, I gave the keynote address at the first “Diagnostic Errors in Medicine” conference, sponsored by the Agency for Healthcare Research and Quality (AHRQ). The meeting was filled with people from a wide variety of disciplines, including clinical medicine, education, risk management, cognitive science, and informatics, all passionate about making diagnosis safer. The atmosphere was electric. My lecture was entitled, “Why diagnostic errors don't get any respect” (I wrote up the speech in my blog and a Health Affairs article, shown) My talk was, admittedly, a downer. Highlighting the fact that diagnostic errors are arguably the most important patient safety hazard (they accounted for 17% of the adverse events in the famous Harvard Medical Practice Study and are usually the number one cause of harm in malpractice cases), I pointed out that from the very start of the patient safety field, relatively little attention had been paid to them.…