Informing health professionals, protecting patients

Richard Smith

Editor, BMJ

Lagos 2001

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?

Utility of information

• Utility=relevance x validity x interactivity work to

access

Source Relevance Validity Ease ofAccess

Utility

Journal Low Moderate Moderate Low tomoderate

Textbook High Moderate/low

Moderate Moderate

Colleague High Moderate/low

High High/moderate

CochraneLibrary

Low High Low Moderate

ClinicalEvidence

High High High High

Current problems with informing professionals

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

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

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 Many of my textbooks are out of date; I would like to purchase new ones, but they are expensive.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 don=t 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

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?

00.1

0.20.3

0.40.5

Lessthan 1%

1%-10% 11%-50%

51%-90%

Morethan90%

Amount read

Perce

ntage

Series2

Series1

Current problems

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

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

Yes

No

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

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.

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

What’s wrong with medical journals

• Don’t meet information needs

• Too many of them

• Too much rubbish

• Too hard work

• Not relevant

• Too boring

• Too expensive

What’s wrong with medical journals

• Don’t add value

• Slow every thing down

• Too biased

• Anti-innovatory

• Too awful to look at

• Too pompous

• Too establishment

What’s wrong with medical journals

• Don=t reach the developing world

• Can’t cope with fraud

• Nobody reads them

• Too much duplication

• Too concerned with authors rather than readers

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

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

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

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

Are patients getting the best treatments?

•Often no

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

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

Are patients safe?

•Not as safe as they should be

Unsafe in two ways

• Damage from rogue doctors

• Damage from medical error

Bristol babies

Harold ShipmanGP murderer

Rodney LedwardBlundering gynaecologist

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"

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

Why do these problems happen?

• Every profession contains rogues

• It’s 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”

Responding to rogues

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

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

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.

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.

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

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.

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

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

How to think of error?

• An individual failing– Only the minority of cases amount from negligence

or misconduct; so it’s 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)

How to think of error?

• A systems failure– This is the starting point for redesigning the

system and reducing error

Raising quality and reducing error

• Clinical governance

• Revalidation

• Government machinery

• Building a safety culture

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

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

Building a safe healthcare system (from James Reason)

• Principles

• Policies

• Procedures

• Practices

Building a safe healthcare system (from James Reason)

• Principles– Safety is everybody’s business– Top management accepts setbacks and

anticipates errors– safety issues are considered regularly at the

highest level– Past events are reviewed and changes

implemented

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

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

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

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

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

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

James Reason’s bottom line

• Fallibility is part of the human condition

• We can’t change the human condition

• We can change the conditions under which people work

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