Informing health professionals, protecting patients

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Informing health professionals, protecting
patients

• Richard Smith
• Editor, BMJ
• Lagos 2001

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What I want to talk about

• The usefulness of information
• Methods for informing professionals
• How are we doing?
• How could we do better?
• Are patients getting the best treatments?
• Are they safe?
• How do we protect patients?
• How could we do better?

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Utility of information

• Utilityrelevance x validity x interactivity
  
  work to access

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Current problems with informing professionals

• A picture that captures in one image how doctors
  feel about information

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Current problems with information supply

• Our current information policy resembles the
  worst aspects of our old agricultural policy,
  which left grain rotting in thousands of storage
  files while people were starving. We have
  warehouses of unused information rotting while
  critical questions are left unanswered and
  critical problems are left unresolved. Al Gore

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Current problems

• On my desk I have accumulated journals and books
  as information sources, and I assume that I use
  them. But in some respects they are not as useful
  as they might be. Many of my textbooks are out of
  date I would like to purchase new ones, but they
  are expensive. My journals are not organised so
  that I can quickly find answers to questions that
  arise, and so I dont have print sources that
  will answer some questions. On the other hand,
  there is likely to be a human source who can
  answer nearly all of the questions that arise,
  albeit with another set of barriers. An ordinary
  doctor

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Current problems

• Think of all the information that you might read
  to help you do your job better.
• How much of it do you read?

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Current problems

• Do you feel guilty about how much or how little
  you read?

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Words used by 41 doctors to describe their
information supply

• Impossible Impossible Impossible Impossible
  Impossible Impossible
• Overwhelming Overwhelming Overwhelming
  Overwhelming Overwhelming Overwhelming
• Difficult Difficult Difficult Difficult
• Daunting Daunting Daunting
• Pissed off
• Choked
• Depressed
• Despairing
• Worrisome

• Saturation
• Vast
• Help
• Exhausted
• Frustrated
• Time consuming
• Dreadful
• Awesome
• Struggle
• Mindboggling
• Unrealistic
• Stress
• Challenging Challenging Challenging
• Excited
• Vital importance

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Conclusions of studies of doctors information
needs during consultations

• Information needs do arise regularly when doctors
  see patients (about two questions per
  consultation)
• Questions are most likely to be about treatment,
  particularly drugs.
• Questions are often complex and multidimensional
• The need for information is often much more than
  a question about medical knowledge. Doctors are
  looking for guidance, psychological support,
  affirmation, commiseration, sympathy, judgement,
  and feedback.

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Conclusions of studies of doctors information
needs during consultations

• Most of the questions generated in consultations
  go unanswered
• Doctors are most likely to seek answers to their
  questions from other doctors
• Most of the questions can be answered - but it is
  time consuming and expensive to do so
• Doctors seem to be overwhelmed by the information
  provided for them

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Whats wrong with medical journals

• Dont meet information needs
• Too many of them
• Too much rubbish
• Too hard work
• Not relevant
• Too boring
• Too expensive

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Whats wrong with medical journals

• Dont add value
• Slow every thing down
• Too biased
• Anti-innovatory
• Too awful to look at
• Too pompous
• Too establishment

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Whats wrong with medical journals

• Dont reach the developing world
• Cant cope with fraud
• Nobody reads them
• Too much duplication
• Too concerned with authors rather than readers

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A vision of something better

• "It's easy to say what would be the ideal online
  resource for scholars and scientists all papers
  in all fields, systematically interconnected,
  effortlessly accessible and rationally navigable,
  from any researcher's desk, worldwide for free.
  Stevan Harnad

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The thing

• The information tool that will answer doctors and
  patients questions within 15 seconds - as they
  consult
• There is a worldwide search for the thing

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Characteristics of the thing

• Must be able to answer highly complex questions--
  so will have to be connected to a large valid
  database
• Electronic
• Portable
• Fast
• Easy to use
• Will prompt doctors rather than simply answer
  questions

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Characteristics of the thing

• Doctors must find it helpful rather than
  demeaning
• Probably be connected to the patient record
• A servant of patients as well as doctors
• Will provide psychological support and
  affirmation.
• Probably there will be no single tool but a
  family of tools

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Are patients getting the best treatments?

• Often no

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Overtreatment

• Many operations are performed inappropriately
• Too many Caeasarean sections
• Medicalisation of birth enemas, pubic shaving,
  episiotomies, intrapartum monitoring
• Overprescribing of antiobiotics
• Overuse of tranquillisers

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Undertreatment

• Rule of halves for most chronic diseases half
  not detected half of those detected not treated
  half of those treated not treated adequately
• Aspirin after heart attacks or stroke
• ACE inhibitors in heart failure
• Statins
• Doses of antidepressants too low

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Are patients safe?

• Not as safe as they should be

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Unsafe in two ways

• Damage from rogue doctors
• Damage from medical error

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Bristol babies
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Harold ShipmanGP murderer
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Rodney LedwardBlundering gynaecologist
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Newspaper headlines11 November 1999

• "University shame of the bogus professor
• "Sterilisation surgeon suspended"
• "Woman had breasts removed in error"
• "Suspect doc in drug probe"
• "Banned test kits still used in NHS hospitals"
• "Stethoscopes and lies"

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How common are these problems?

• Over a five year period concerns serious enough
  to warrant the consideration of disciplinary
  action were raised about 6 of all senior medical
  staff (49/850).
• 96 types of problem were encountered
• Poor attitude and disruptive or irresponsible
  behaviour (32)
• Lack of commitment to duties (21)
• Poor skills and inadequate knowledge (19),
  Dishonesty (11)
• Sexual matters (7)
• 25 of the 49 doctors retired or left the
  employer's service

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Why do these problems happen?

• Every profession contains rogues
• Its especially easy to get away with it in the
  NHS
• Poor surveillance, particularly of single handed
  GPs
• There but for the grace of God go I
• All doctors are problem doctors

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Responding to rogues

• Its not easy
• Patients
• Colleagues--? In Nigeria
• Criminal justice system
• GMC
• Commission for Health Improvement
• National Patient Safety Agency
• Machinery to improve quality

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How common is error?

• Harvard Medical Practice Study
• Reviewed medical charts of 30 121 patients
  admitted to 51 acute care hospitals in New York
  state in 1984
• In 3.7 an adverse event led to prolonged
  admission or produced disability at the time of
  discharge
• 69 of injuries were caused by errors

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How common is medical error?

• Australian study
• Investigators reviewed the medical records of 14
  179 admissions to 28 hospitals in New South Wales
  and South Australia in 1995.
• An adverse event occurred in 16.6 of admissions,
  resulting in permanent disability in 13.7 of
  patients and death in 4.9
• 51 of adverse events were considered to have
  been preventable.

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Results of medical error

• In Australia medical error results in as many as
  18 000 unnecessary deaths, and more than 50 000
  patients become disabled each year.
• In the United States medical error results in at
  least 44 000 (and perhaps as many as 98 000)
  unnecessary deaths each year and 1 000 000 excess
  injuries.

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Types of error

• About half of the adverse events occurring among
  inpatients resulted from surgery.
• Next come
• Complications from drug treatment
• therapeutic mishaps
• diagnostic errors were the most common
  non-operative events. In the Australian study
  cognitive errors, such as making an

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Types of error

• Cognitive errors--such as incorrect diagnosis or
  choosing the wrong medication-- more likely to
  have been preventable and more likely to result
  in permanent disability than technical errors.

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How dangerous is health care?

• Less than one death per 100 000 encounters
• Nuclear power
• European railroads
• Scheduled airlines
• One death in less than 100 000 but more than 1000
  encounters
• Driving
• Chemical manufacturing
• More than one death per 1000 encounters
• Bungee jumping
• Mountain climbing
• Health care

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Why do errors happen?

• All humans make errors indeed, the ability to
  make mistakes allows human beings to function
• Most of medicine is complex and uncertain
• Most errors result from the system--inadequate
  training, long hours, ampoules that look the
  same, lack of checks, etc
• Healthcare has not tried to make itself safe

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How to think of error?

• An individual failing
• Only the minority of cases amount from negligence
  or misconduct so its the wrong diagnosis
• It will not solve the problem--it will probably
  in fact make it worse because it fails to address
  the problem
• Doctors will hide errors
• May destroy many doctors inadvertently (the
  second victim)

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How to think of error?

• A systems failure
• This is the starting point for redesigning the
  system and reducing error

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Raising quality and reducing error

• Clinical governance
• Revalidation
• Government machinery
• Building a safety culture

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Two ideas from clinical governance

• Boards of hospitals have always legal and
  financial governance
• The quality of clinical care was the
  responsibility of professionals
• Now the boards are responsible for the quality of
  clinical care
• This requires new ways of thinking

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Revalidation

• Guaranteeing to patients that doctors are safe,
  competent, professional, ethical, and up to date
• Will happen every five years
• Not so easy
• A record on attending education is not enough
• Need data on practice and outcomes
• Linked to appraisal

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Building a safe healthcare system (from James
Reason)

• Principles
• Policies
• Procedures
• Practices

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Building a safe healthcare system (from James
Reason)

• Principles
• Safety is everybodys business
• Top management accepts setbacks and anticipates
  errors
• safety issues are considered regularly at the
  highest level
• Past events are reviewed and changes implemented

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Building a safe healthcare system (from James
Reason)

• Principles
• After a mishap management concentrates on fixing
  the system not blaming the individual
• Understand that effective risk management depends
  on the collection, analysis, and dissemination of
  data
• Top management is proactive in improving
  safety--seeks out error traps, eliminates error
  producing factors, brainstorms new scenarios of
  failure

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Building a safe healthcare system (from James
Reason)

• Policies
• Safety related information has direct access to
  the top
• Risk management is not an oubliette
• Meetings on safety are attended by staff from
  many levels and departments
• Messengers are rewarded not shot
• Top managers create a reporting culture and a
  just culture

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Building a safe healthcare system (from James
Reason)

• Policies
• Reporting includes qualified indemnity,
  confidentiality, separation of data collection
  from disciplinary procedures
• Disciplinary systems agree the difference between
  acceptable and unacceptable behaviour and involve
  peers

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Building a safe healthcare system (from James
Reason)

• Procedures
• -Training in the recognition and recovery of
  errors
• Feedback on recurrent error patterns
• An awareness that procedures cannot cover all
  circumstances on the spot training
• Protocols written with those doing the job
• Procedures must be intelligible, workable,
  available

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Building a safe healthcare system (from James
Reason)

• Procedures
• Clinical supervisors train their charges in the
  mental as well as the technical skills necessary
  for safe and effective performance

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Building a safe healthcare system (from James
Reason)

• Practices
• Rapid, useful, and intelligible feedback on
  lessons learnt and actions needed
• Bottom up information listened to and acted on
• And when mishaps occur
• Acknowledge responsibility
• Apologise
• Convince patients and victims that lessons
  learned will reduce chance of recurrence

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James Reasons bottom line

• Fallibility is part of the human condition
• We cant change the human condition
• We can change the conditions under which people
  work

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Conclusions

• There is huge room for improvement within health
  care and the dissemination of medical information
• The internet and information technology offer
  great possibilities for improvement
• Patients are at high risk of poor treatment and
  medical error and at lower risk of abuse by a
  rogue doctor
• The response depends more on changing systems
  than individuals