Maryn McKenna

Journalist and Author

  • Contact
  • Blog
  • Speaking and Teaching
  • Audio & Video
    • Audio
    • Video
  • Journalism
    • Articles
    • Past Newspaper Work
  • Books
    • Big Chicken
    • SuperBug
    • Beating Back the Devil
  • Bio
  • Home

One more set of recommendations

August 13, 2009 By Maryn Leave a Comment

… and then next week I’ll be back to analyzing the medical literature: A stack of interesting new journal articles is threatening to topple and bury my computer.

For the moment, though:

First, the Hearst newspapers chain has conducted a nationwide investigation into medical errors that should be required reading for anyone who wonders why hospitals can’t do a better job controlling hospital-acquired infections. It is a 7-part series focusing on the 5 states (New York, Texas, California, Connecticut, Washington) where there are Hearst papers, and hosted on the site of the San Francisco Chronicle. The introductory article says:

Ten years ago, a highly publicized federal report called the death toll shocking and challenged the medical community to cut it in half — within five years.
Instead, federal analysts believe the rate of medical error is actually increasing.
A national investigation by Hearst Newspapers found that the medical community, the federal government and most states have overwhelmingly failed to take the effective steps outlined in the report a decade ago.
… in five states served by Hearst newspapers — New York, California, Texas, Washington and Connecticut — only 20 percent of some 1,434 hospitals surveyed are participating in two national safety campaigns begun in recent years.
Also, a detailed safety analysis prepared for Hearst Newspapers examined discharge records from 1,832 medical facilities in four of those states. It found major deficiencies in patient data states collect from hospitals, yet still found that a minimum of 16 percent of hospitals had at least one death from common procedures gone awry — and some had more than a dozen. (Byline: Cathleen F. Crowley and Eric Nalder)

From that opening statement, the investigation goes on to explore many patient stories that individually are tragedies and collectively — as we here know all to well — are a scandal.

There is just one notable MRSA story in the mix, the death of a retired hospital president who contracted the bug in his own hospital. But they are all worth reading.

Second, an executive and apparently new writer named David Goldhill has written for The Atlantic a passionate and well-thought out piece on his father’s death from a hospital-acquired infection and on what needs to change for such deaths to never happen again. “My survivor’s grief has taken the form of an obsession with our health-care system,” he writes:

My dad became a statistic—merely one of the roughly 100,000 Americans whose deaths are caused or influenced by infections picked up in hospitals. One hundred thousand deaths: more than double the number of people killed in car crashes, five times the number killed in homicides, 20 times the total number of our armed forces killed in Iraq and Afghanistan. Another victim in a building American tragedy.

You may not agree with his conclusions, but it is worth reading through to the end to experience how one intelligent citizen from outside health care understands and attempts to re-think our broken system.

Filed Under: checklist, health policy, hospitals, human factors, medical errors, MRSA, nosocomial

How hospitals are like cockpits

April 7, 2009 By Maryn Leave a Comment

We’ve talked a couple of times about the growing push for checklists in surgery and elsewhere in hospitals, promoted by Hopkins professor and MacArthur “genius” grant-winner Dr. Peter Provonost and modeled on the use of checklists in aviation. (This stuff interests me not just because it offers so much promise for MRSA reduction but because, as constant readers will remember, I am a pilot and am married to an avionics engineer.)

Provonost and colleagues have a very interesting piece in the current Health Affairs that takes another aviation concept — the Commercial Aviation Safety Team (CAST) — and applies it to medical errors. CAST is a public-private partnership from across the aviation spectrum — government, airlines, labor, manfacturers — that came together in the wake of several terrible accidents to do system-wide analyses of fail points. Provonost proposes that health care could vastly reduce errors by implementing a CAST model.

The cite is: Provonost, PJ, Goeschel CA, Olsen KL et al. Reducing Health Care Hazards: Lessons From The Commercial Aviation Safety Team. Health Affairs 28, no. 3 (2009): w479-w489 (published online 7 April 2009; 10.1377/hlthaff.28.3.w479)]

Filed Under: aviation, checklist, hospitals, medical errors, nosocomial

US Air 1549 and the relevance of checklists

January 19, 2009 By Maryn Leave a Comment

Constant readers, when we discussed the importance of surgical checklists last week, I mentioned parenthetically that I am a licensed pilot. (For av geeks: single engine, taildragger, VFR. And, just to complete the geekery, married to an avionics engineer.) So I’ve been particularly fascinated by the story and back-story of US Air flight 1549, which — as I am sure most of you know — bellied into the Hudson last week after losing both its engines to bird ingestion and landed beautifully, with no injuries to its passengers or crew.

The landing is being called a miracle, but to a pilot, it’s no miracle: It’s a testament to excellent performance under pressure by pilot-in-command Chesley “Sully” Sullenberger III and his first officer and crew. How did they perform so well? They ran down a checklist. Why did they reach for the checklist immediately, almost instinctively, and perform so well as a group? Because they trained many, many, many times to do exactly that.

Last week’s New England Journal of Medicine article made clear the value of checklists to medicine. But patient-safety analyst Bob Wachter asks an additional vital question: Even when medicine has such measures, how often do we train to implement them? The answer, he finds, is not often:

We need to continue to work, as aviation has for the past generation, to train our “pilots” to become Sullys. Because we in healthcare are flying over some pretty cold rivers, each and every day.

(Hat tip to KevinMD.com for calling attention to Wachter’s post.)

Filed Under: aviation, checklist, human factors, medical errors

Reducing errors: Worldwide proof that it’s not so hard

January 14, 2009 By Maryn Leave a Comment

There’s an encouraging joint announcement coming this afternoon from the World Health Organization and the New England Journal of Medicine. (I’ve set the timer on this post to publish when the embargo lifts.)

Using a simple but detailed checklist, eight hospitals in a mix of high-income and resource-poor areas were able to reduce their rates of surgical complications by one-third and their rate of death due to surgical complications by almost one-half.

The checklist study was sponsored by the WHO’s Safe Surgery Saves Lives campaign. It was headed by surgeon and author Atul Gawande, MD, who is lead author of the NEJM paper and has spoken passionately about checklists as a simple, reliable, reproducible, low-cost intervention that can return extraordinary improvements.

The checklist idea originates in medicine with Dr. Peter Provonost, Johns Hopkins University critical-care researcher and MacArthur “genius” fellow. Gawande wrote a profile of Provonost, and plea for checklist implementation, in the New Yorker in Dec. 2007, and followed that article two weeks later with a New York Times op-ed piece.

The checklist idea has been borrowed from other tech-intensive fields, notably aviation. As a licensed pilot, I can testify that no pilot or crew, no matter how experienced, would ever dare take off without running through a checklist. To believe that you can keep everything you need to do in your head without reference to an external reminder is, in aviation, simply not a credible position. It is considered an absurd display of ego that puts others at unnecessary risk. (For a taste of how aviation looks at medicine’s resistance to improvement, see Sir Richard Branson’s comments last month.)

In the current study, one hospital in each of eight cities — Toronto, New Delhi, Amman, Auckland, Manila, London, Seattle and Ifakara, Tanzania — agreed to follow a pre-, during- and post-surgery checklist for every noncardiac surgery on patients older than 16. The study group collected data before implementation of the checklist on 3,733 consecutively enrolled patients, and during the checklist implementation, on 3,955 patients.

The checklist is on the WHO website (.pdf in English) along with toolkits for implementation. If you look, you’ll see it is very simple. For instance, before anesthesia:

  • Patient has confirmed: identity, site, procedure, consent
  • Site marked (or marking confirmed not applicable)
  • Anaesthesia safety check completed
  • Pulse oximeter on patient and functioning
  • Does patient have a known allergy? (No/Yes)
  • Does patient have a difficult airway/aspiration risk? (No/Yes, and equipment/assistance available)
  • Is there a risk of >500ml blood loss (7ml/kg in children)? (No/Yes, and adequate intravenous access and fluids planned)

There are similar short, thorough and noncomplex checklists for before skin incision and before patient leaves the operating room. Amazingly — or not, for those of you who follow the struggle against medical errors — these interventions, simple as they are, were new to most of the study hospitals.

Now, the research team is careful to point out the possible confounders to this study: It introduced changes in systems at the hospitals that may have created independent effects. It may suffer from the Hawthorne effect (“Observation changes the behavior of the observed.”) Given that it used consecutively enrolled patients, it may be affected by secular trends at the individual institutions. And it does not track complications post-discharge.

All that being said, I think we can take this as a very potent argument for the adoption of surgical checklists as a component of campaigns to reduce medical errors. And, as Gawande says in the press release that WHO put out this afternoon, a pointer to possible improvements in other specialties as well:

These findings have implications beyond surgery, suggesting that checklists could increase the safety and reliability of care in numerous medical fields… [I]n specialties ranging from cardiac care to pediatric care, they could become as essential in daily medicine as the stethoscope.

The cite on the study is: Haynes, AB, Weiser, TG, Berry, WR et al. Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. N Eng J Med 2009: 260: 491-9. Published ahead of print Jan. 14, 2009.

UPDATE: The full text has been placed online for free.

Filed Under: checklist, hospitals, human factors, medical errors, surgery, WHO

© [fl_year} Maryn McKenna | Web Design Services by Sumy Designs, LLC

Facebook