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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
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 rottingwhile 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 Many of my textbooks are out of date; I would like to purchase new ones, but they are expensive.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?
Current problems • Do you feel guilty about how much or how little you read?
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 Words used by 41 doctors to describe their information supply
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
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