Archivi Categorie: Patient safety

The Courage And Triumph Of The Patient @Medici_Manager @acpatient @leadmedit @pash22

Leah Binder Contributor

Improving the “patient experience” is a trending topic in health policy circles these days, the subject of many new conferences and journal articles. Providers puzzle over this. How can they improve patient “compliance” and “adherence” to doctor’s orders? What are the techniques to educate patients on “self-management”? How can we better coordinate the various services offered to each patient so the patient doesn’t fall through the cracks?

It is gratifying to see this emphasis on patients. Yet many providers still do not grasp that improving patient experience requires something more than studying the issue and implementing a few new policies. It requires nothing short of a paradigm shift in the way they think about their role in the patient’s life and the fundamentals of their practice.

The best example of providers misunderstanding the depth of this issue is how the influential provider-governed Beryl Institute defines the patient experience: “the sum of all interactions, shaped by an organization’s culture that influence patient perceptions across the continuum of care.” In other words, Beryl believes that the patient experience is the patient’s reaction to what providers do.

Trust me, that is not how patients view their own experience.

“Momma had her last radiation treatment today,” a young woman I’ll call Karen posted on Facebook last June. “Can’t even explain the amount of strength and courage that crazy lady has shown and I couldn’t be more proud to call her my Mom.”

Patients and their families see their experiences as Karen did, as the act of summoning every last reserve of strength and courage to endure each minute, one day at a time. Patients don’t see themselves as mere recipients of services. Patients and their families don’t talk about self-management or compliance or adherence. They find themselves in an epic story of survival and adventure. They are the reluctant heroes of that personal drama, Odysseus setting forth on the ultimate journey. Some patients are ready and some aren’t, but every patient is forced to try their best, since the road is before them.

One of the country’s leading thinkers on the patient experience is Dave deBronkart, who miraculously survived Stage 4 kidney cancer. His mantra (and the title of the book he coauthored): “Let Patients Help.” DeBronkart advises providers to recognize patients as journeymen, not baggage, in the quest toward recovery. He speaks to provider groups throughout the world, and gave one of the most popular TED talks ever, all with an eye toward reframing the way the health care system engages patients and insisting that patients are part of the cure, not passive recipients of care. He says that patient knowledge and wisdom and willingness to research are a wealth of untapped resources.

Most of us know someone like Karen, Karen’s mom or Dave, who stood up and squarely faced the worst news imaginable. Though doctors work with patients every day, there is something very different about being on the other side of the fence, as deBronkart’s co-author Dr. Danny Sands movingly recounts in his blog about suffering life-threatening seizures.

Providers can nurture, coach, mentor, guide and be humble enough to realize they have only a small – though critical – role to play in the larger life story of the human beings they call patients. Providers succeed when they recognize they aren’t treating a disease or filling an empty vessel with “services,” but coaching a complex person with a destiny and a legacy who, for better or worse, is the hero of her own life.

I’m sad to report that Karen’s “crazy lady” mother, Susan, 52, died from breast cancer a few days ago. Susan was beloved throughout her rural Maine community, an exceptional teacher, community volunteer, mother. She had a very special gift with children, many of whom are traveling from far and wide to come to the funeral of this woman they revered.

“I believed a miracle would happen and she would beat this beast,” said Susan’s dear friend Kathleen, “She fought the most courageous fight I’ve ever witnessed. Heaven is so lucky to have this new angel.”

In my opinion, Susan did win, though not the way we all hoped for. But a life well-lived is the ultimate triumph. “To have been given 22 years with you was such a blessing.” Karen wrote in an open letter the day her mother died. “I promise with all my heart to be the fun loving, positive and slightly wacky person you’ve taught me to be. Thank you for all the amazing memories Momma Bear.”

Susan’s a winner and so are the many excellent physicians and nurses who cared for her through her battle with cancer. As the famous doctor Patch Adams once said, “You treat a disease, you win, you lose. You treat a person, I guarantee you’ll win.” The patient experience is more the stuff of Shakespeare than Gray’s Anatomy. Providers with that wisdom will transform health care forever.

“Dove e come mi curo”: trasparenza e informazione anche in Italia @Medici_Manager @WRicciardi

Walter Ricciardi

Dal 25 ottobre scorso – in virtù della direttiva europea 2011/24/UE – ogni cittadino dell’Unione Europea può decidere liberamente di ricevere assistenza sanitaria in ciascuno dei 28 Paesi membri.

È chiaro che, per scegliere il luogo dove curarsi, un cittadino dovrebbe avere accesso ad informazioni chiare, rigorose e tempestive sulla qualità dei servizi offerti, sia ospedalieri (quelli che giustificano il sacrificio di spostarsi da casa propria per avere cure adeguate), sia ambulatoriali e domiciliari. Proprio per questo motivo la direttiva UE raccomandava ai Paesi membri di attivare strumenti, soprattutto su internet, per informare i propri cittadini: in Inghilterra, ad esempio, questi dati sono disponibili da anni e, addirittura, dallo scorso luglio, sono disponibili on line i dati relativi ai singoli professionisti.

In Italia mancava finora un database informativo destinato ad orientare le scelte dei cittadini in ambito sanitario.

Questo sito ‘Dove e come mi curo’ nasce proprio per riempire questo vuoto e aiutare gli italiani a trovare le migliori strutture sanitarie cui rivolgersi per una certa patologia, ma anche per rendere tali strutture attrattive per gli stranieri.

Esso è il frutto di oltre due anni di difficile lavoro di un gruppo di ricercatori, supervisionati da un Comitato Scientifico di assoluto valore internazionale, che ha raccolto, elaborato e spiegato in modo semplice i complessi – spesso incomprensibili ai non addetti ai lavori – dati ed indicatori sanitari per permettere di scegliere dove e come curarsi in modo adeguato.

È un primo passo verso un sistema sanitario più trasparente e verso una partecipazione più attiva ed informata dei cittadini a quello che è ancora uno dei Servizi Sanitari migliori del mondo, ma ha al suo interno enormi diversità che rendono difficile per il cittadino orientarsi.

Ad oggi, è stato possibile includere soltanto alcune problematiche per cui erano disponibili dati ed informazioni pubbliche, ma vi sono ancora tante situazioni che interessano milioni di italiani che non hanno strumenti per scegliere in modo adeguato il proprio luogo di cura.

Confidiamo che la futura collaborazione sia con singoli cittadini, sia con le più importanti associazioni di pazienti che svolgono un lavoro importantissimo in merito, sia con le stesse organizzazioni sanitarie, possa ulteriormente ampliare e migliorare il sito, per la salute dei cittadini e per il bene del nostro Servizio Sanitario Nazionale.

Preventing excess @Medici_Manager @pash22 @helenbevan @muirgray

by Ray Moynihan

IN recent weeks the world’s leading medical journals have published articles about the overtreatment of mild hypertension, the risks of breast cancer overdiagnosis, and the lack of effectiveness and potential harms of general health checks.

As the studies of dangerous excess mount, so too does the effort to raise awareness about the problem. JAMA Internal Medicinenow has a regular “Less is more” feature, the BMJ has just launched its “Too much medicine”  campaign, and professional societies in the US are running the “Choosing wisely” initiative, highlighting overused tests and treatments.

In the field of mental health few could have missed the global fight over the DSM–5 and vociferous claims it will further fuel the medicalisation of normal life.

There’s little doubt that the market-based system in the US is the epicentre of excess — where health care now comprises almost one-fifth of the entire economy — but the problem affects many nations.

With breast cancer for example, estimates based on incidence studies suggest one-third of invasive cancers diagnosed by screening mammography in NSW may be overdiagnosed — in other words, the cancer would not have gone on to harm the woman.

The probable causes of overdiagnosis and overtreatment are complex — technological change, commercial gain, professional imperialism, fears of litigation, perverse incentives and our deep cultural faith in early detection. But despite the complexity and enormity of the challenge, it’s surely time to try to work out how we can wind back the harms of too much medicine.

A group of Australian researchers are a key driving force behind the first international scientific conference on overdiagnosis to be held in the US this September. The Dartmouth Institute for Health Policy and Clinical Practice is a logical host for the Preventing Overdiagnosis conference, with its proud history of medical scepticism and impeccable credentials on the dangers of too much medicine.

Resulting from a small meeting on Queensland’s Gold Coast last year, the conference is being run in partnership with the BMJ and one of the world’s most influential consumer organisations,Consumer Reports. It will feature 90 scientific presentations on the problem and its solutions, and keynote speakers include Dr Virginia Moyer, the chair of the US Preventive Services Task Force, Dr Allen Frances, chair of the DSM IV, and Dr Barry Kramer, a senior director at the National Cancer Institute, which has made overdiagnosis one of its research priorities.

Along with the research and the conferences, the time is ripe for a lot more discussion about what can be done in the clinic and the classroom, how we can communicate the counterintuitive message that less is sometimes more, and how we can develop and evaluate effective policy responses.

The aim, after all, is not just more meetings and peer-reviewed papers, but fewer healthy infants labelled unnecessarily with gastro-oesophageal reflux disease, less distress overdiagnosed as mental illness, and fewer of our elders assailed by out-of-control polypharmacy. The less we waste on unnecessary care, the more resources there are for those in genuine need.

Along with innovations in genetics and information technology, one of the exciting areas in medicine in the 21st century will be how to wind back unnecessary excess — safely and fairly.

Ray Moynihan is a senior research fellow and PhD student at Bond University, and co-organiser of the Preventing Overdiagnosis conference being held at Dartmouth, US, 10–12 September 2013.

What if an airplane was an operating room? @Medici_Manager

Le checklists sono un utile strumento per praticare la sicurezza, non un orpello burocratico da “compilare”!!!!!

Some older adults get unnecessary colonoscopies @Medici_Manager

(Reuters Health) – Close to one-quarter of colonoscopies performed on older adults in the U.S. may be uncalled for based on screening guidelines, a new study from Texas suggests.

Researchers found rates of inappropriate testing varied widely by doctor. Some did more than 40 percent of their colonoscopies on patients who were likely too old to benefit or who’d had a recent negative screening test and weren’t due for another.

Guidelines from the U.S. Preventive Services Task Force, a government-backed panel, recommend screening for colon cancer – every 10 years, if it’s done with colonoscopy – between age 50 and 75.

After that point, “It involves an unnecessary risk with no added benefit for these older patients,” said Kristin Sheffield, the new study’s lead author from the University of Texas Medical Branch in Galveston.

Those risks include bowel perforation, bleeding and incontinence, as well as the chance of having a false positive test and receiving unnecessary treatment.

Even for screening tests that are universally recommended for middle-aged adults, the balance of benefits and risks eventually points away from screening as people age. Any cancers that are caught might never have shown up during a patient’s lifetime if the person is too old or the cancer too slow-growing.

But because there has been so much effort to educate the public about reasons to get screened, the potential harms are often overlooked – and the idea of stopping screening isn’t regularly discussed, researchers said.

Sheffield and her colleagues looked at Medicare claims data for all of Texas and found just over 23 percent of colonoscopies performed on people age 70 and older were possibly inappropriate.

For patients age 76 to 85, as many as 39 percent of the tests were uncalled for, the researchers wrote Monday in JAMA Internal Medicine. The rest were likely done for diagnostic purposes.


Another study published in the same journal supports the idea that many Americans are so focused on the possible benefits of screening that they don’t realize harms are involved as well.

Dr. Alexia Torke from the Indiana University School of Medicine in Indianapolis and her colleagues surveyed 33 adults between age 63 and 91 and found many saw screening as a moral obligation.

Few of the older adults had discussed the possibility of stopping routine screening, such as for breast cancer, with their doctor, and some told the researchers they would distrust or question a doctor who recommended they stop.

“There’s very limited data for any cancer test that it leads to any benefit for older adults,” said Dr. Mara Schonberg, from Beth Israel Deaconess Medical Center and Harvard Medical School in Boston.

“You want to be doing this thinking it’s going to be helping you live longer,” she told Reuters Health – especially because the chance of suffering side effects from screening or treatment may be higher among older people.

Schonberg, who wrote a commentary on Torke’s study, said time spent unnecessarily screening older adults may take away from conversations that could actually benefit their health – such as about exercise and eating better.

“There’s really a strongly held belief that you need to get screened, that it’s irresponsible if you don’t,” said Dr. Steven Woloshin, who has studied attitudes toward screening at the Geisel School of Medicine at Dartmouth in Hanover, New Hampshire.

“There have been all these messages for years about the importance of screening that people have been inundated with, and I think it’s really hard to change the message now, even though it’s become clear that screening is a double-edged sword,” Woloshin, who wasn’t involved in the new research, told Reuters Health.

The researchers agreed screening should be an individual decision as people get older, but that everyone should fully understand what they stand to gain – if anything – and what they could lose by getting screened.

For colon cancer in particular, Sheffield recommended elderly people who really want to be screened go with a less-invasive method than colonoscopy, such as fecal occult blood testing.


In another analysis of Medicare beneficiaries undergoing colonoscopy, researchers led by Dr. Gregory Cooper from Case Western Reserve University in Cleveland learned the proportion of procedures using anesthesia – most likely propofol – increased from less than nine percent in 2000 to 35 percent in 2009.

The cost of a procedure using anesthesia is about 20 percent higher than one without it, the researchers noted.

Patients in their study suffered a complication – including perforation or breathing problems – during one in 455 procedures using anesthesia, compared to one in 625 without anesthesia. The researchers said so-called deep sedation may impair patients’ airway reflexes and blunt their ability to respond to procedure-related pain.

SOURCE: JAMA Internal Medicine, online March 11, 2013.

Colonoscopy ‘Potentially Inappropriate’ for 30% of Seniors @Medici_Manager

Cheryl Clark, for HealthLeaders Media, March 12, 2013

During the year after an influential U.S. task force advised providers to stop routine screening colonoscopies in seniors over age 75 because risks of harm outweigh benefits, as many as 30% of these “potentially or probably inappropriate” procedures were still being performed, with huge pattern variation across the nation, especially in Texas.

“We found that a large proportion of colonoscopies that are performed in these older patients were potentially inappropriate based on age-based screening guidelines,” says Kristin Sheffield, PhD, assistant professor of surgery at the University of Texas Medical Branch at Galveston, lead researcher of the study.

For patients between 70 and 74, “procedures were repeated too soon after a negative exam,” increasing the odds of avoidable harm, such as “perforations, major bleeding, diverticulitis, severe abdominal pain or cardiovascular events,” she says. The guidance, from the U.S. Preventive Services Task Force, which was released in 2008, also set a 10-year interval for routine colonoscopies for people between age 70 to 75 unless the patient develops certain symptoms.

The task force’s prior guidance issued in 2002 had no age limit recommendation, Sheffield says.

“For some physicians, more than 30% of the colonoscopies they performed were potentially inappropriate according to these screening guidelines,” she says. “So this variation suggests that there are some providers who are overusing colonoscopy for screening purposes in older adults,” Sheffield said.

Her report, published in this week’s JAMA Internal Medicine,looked at Medicare data from the Dartmouth Atlas between October 1, 2008 and September 30, 2009, to see hospital referral region patterns of variation across the nation as a whole. For the state of Texas, Sheffield used claims data from smaller hospital service areas, so she could see practices of individual physicians who performed colonoscopies.

She discovered that Medicare beneficiaries were much less likely to have a “potentially or probably inappropriate” colonoscopy if they lived in a non-metropolitan or rural area. Practitioners who were more likely to perform potentially or probably inappropriate colonoscopies were more likely to have been graduated from medical school before 1990 rather than after, and were more likely to perform a higher volumes of the procedure on Medicare beneficiaries each year.

The data was de-identified, so as not to reveal the practice pattern of an individual physician by name.

“Our purpose was not to point fingers at individual physicians or specialties. We just wanted to examine patterns in potentially inappropriate colonoscopy, because patterns can illustrate issues in everyday practice. It can help illuminate and show the range of practice in terms of the range of inappropriate colonoscopies.

Sheffield says that it may be that colonoscopists were simply slow to adapt the recommendations to their practices in certain parts of the country. In a subset of cases, she acknowledges, there may have been legitimate reasons why a physician recommended the procedure in a patient, and perhaps failed to code it properly for the claims database.

“For example, in adults between the ages of 76 to 85, there are some considerations that would support the use of screening colonoscopy, for example, a patient has a higher risk of developing an adenoma. But in general, screening guidelines indicate that should be exception, rather than the rule.”

And if that were the case, there wouldn’t be such a huge variation. For example, in the wedge of west Texas that includes El Paso, the percentages of colonoscopies that were potentially inappropriate was between 13.3% and 18.79%. But in large areas including Austin, Corpus Christi, San Antonio Houston, and Waco, the percentages ranged between 23.3% and 34.9%.

Nationally, areas of higher potentially inappropriate colonoscopies­—with rates between 25.27% and 30.51%— included eastern Washington state, Idaho, and eastern Nevada, Minnesota, parts of North and South Dakota, all of New England, Arkansas and large portions of North Carolina and Tennessee.

Low utilization areas—with rates between 19.45% and 22.64% — included New Mexico and north Texas, Central and Northern Inland areas of California, and all parts of Florida except Pensacola and areas of South Florida.

The issue included a related article and related commentary.

In the related article, Alexia M. Torke, MD, and colleagues, of the Indiana University for Aging Research, interviewed several dozen patients about their reasons for screening. They found that these patients considered screening at their age to be an automatic part of healthcare, and “a moral obligation.”

For example, one told investigators that discontinuation of routine colonoscopy screening, at age 84, “would be the same as me taking my life. And that’s a sin.”

Discontinuation would mean a much more difficult and significant decision they would have to make.

And they were skeptical of recommendations that they should not have screening, saying it would threaten their trust in their doctors and make them suspicious that a guideline they shouldn’t be screened was made only to save money.

“Public health education and physician endorsements (of cancer screening) may have created a high degree of ‘momentum’ for continuation screening, even in situations in which the benefits may no longer outweigh the risks or burdens.”

In an invited commentary, Mara Schonberg, MD, MPH, of Harvard Medical School and Beth Israel Deaconess Medical Center in Boston, noted that as much as colonoscopies are celebrated as a preventive therapy, they also cause harm.

“Harms of cancer screening are immediate and include pain and anxiety related to the screening test, complications…(e.g., bowel perforation from colonoscopy,) or additional tests after a false positive result, and overdiagnosis (finding tumors that would never cause symptoms in an older adult’s lifetime). Overdiagnosis is particularly concerning because some older adults experience significant complications from cancer treatment.”

She blames “unbalanced public health messages” for contributing to “perceptions that cancer screening should be continued indefinitely,” she also points to the physician’s recommendation as a strong driver of whether a senior citizen undergoes one.

Cheryl Clark is senior quality editor and California correspondent for HealthLeaders Media. She is a member of the Association of Health Care Journalists.

AHRQ Identifies Top 10 Patient Safety Strategies @Medici_Manager @WRicciardi

Laurie Barclay, MD

The Agency for Healthcare Research and Quality (AHRQ) has identified the top 10 patient safety strategies (PSSs) ready for immediate use. Paul G. Shekelle, MD, PhD, from the RAND Corporation, Santa Monica, California, and colleagues present the list in a special supplement to the Annals of Internal Medicine published online March 4. These interventions, if widely implemented, could dramatically enhance patient safety and save lives by reducing medication errors, bed sores, and healthcare-associated infections.

“Wide-scale reductions in patient harm have been modest despite over a decade of research, improvement, and effort since the Institute of Medicine’s ‘To Err is Human’ report,” Patrick W. Brady, MD, told Medscape Medical News in an email interview. “Since that report, the evidence base for safety strategies has continued to grow, but great challenges exist in taking these strategies to scale throughout health systems,” said Dr. Brady, an assistant professor in the Division of Hospital Medicine and the James M. Anderson Center for Health Systems Excellence, Department of Pediatrics, University of Cincinnati, Ohio, who was not involved in the AHRQ project.

According to a journal news release, diagnostic errors result in between 44,000 and 80,000 annual deaths in the United States alone, and bed sores lead to another 68,000 deaths. Thousands more patients die each year as a result of communication errors or failure to receive evidence-based interventions.

During the last 4 years, Dr. Shekelle and colleagues conducted an evidence based assessment of PSSs, including 79 strategies identified in the 2001 AHRQ report, Making Health Care Safer: A Critical Analysis of Patient Safety Practices. On the basis of that assessment and subsequent input from clinicians, researchers, and policymakers regarding the epidemiology of errors and preventable harms, the investigators identified the top 10 PSSs, as well as 31 additional PSSs.

“The team of patient safety experts who put this list together are among the most respected safety experts in the world,” Nancy Foster, vice president of quality and patient safety policy at the American Hospital Association, told Medscape Medical News in an email interview. “The strategies they have identified are effective, important, and should be on the top of every healthcare leader’s list for consideration.”

AHRQ’s Top 10 Patient Safety Strategies

  • preoperative and anesthesia checklists to reduce operative and postoperative events;
  • bundles including checklists to reduce septicemia associated with central lines;
  • catheter reminders, stop orders, nurse-initiated removal protocols, and other interventions to limit urinary catheter use;
  • bundles to prevent ventilator-associated pneumonia, including head-of-bed elevation, sedation vacations, oral care with chlorhexidine, and subglottic suctioning endotracheal tubes;
  • hand hygiene;
  • do-not-use list for hazardous abbreviations;
  • multicomponent interventions to help prevent pressure ulcers;
  • barrier precautions to reduce healthcare-associated infections;
  • central line placement guided by real-time ultrasonography; and
  • strategies to improve venous thromboembolism prophylaxis.

“It is as important for hospital and health system leaders to know why some strategies are not on the list as to know what is on the list,” Foster said, wondering about the absence from the list of adoption of electronic health records despite robust decision support. “Is the evidence still emerging? Were they concerned about emerging evidence of some of the risks from use of [electronic health records]?”

Dr. Brady largely agreed with the list but noted that it could be the “source of some spirited debate.” He commended AHRQ for recommending strategies supported by excellent systematic review and/or research designs including randomized trials and comparative effectiveness studies.

“The considerations used by the authors [regarding] scope of problem addressed, strength of evidence of strategy effectiveness, potential for unintended consequences, cost, and difficulty of implementation are logical and will advance the field of patient safety science,” Dr. Brady said.

Implications for Patient Safety

Foster identified 3 challenges to finding the underlying causes of medical errors and strategies for reducing them: budget cuts affecting AHRQ research, rarity of some errors hindering determination of causes and solutions, and multiple causes underlying some errors, which necessitate use of bundled strategies.

“Medical errors are a worldwide problem that can affect many, many patients and their families, and the AHRQ has safety research as one of its missions, but its entire budget is miniscule compared to that of [the National Institutes of Health], and within AHRQ, patient safety is…only one of the important components,” Foster said. “If we want to resolve the problem, we need a sustained and significant investment in patient safety research, which would mean increasing AHRQ’s budget even in this era of federal budget cuts.”

The payoff could be dramatic. The American Hospital Association recently reported that their Hospital Engagement Network of nearly 1600 hospitals had a 40% reduction in central line bloodstream infections using the bundle recommended by AHRQ, and preliminary results on the implementation of the catheter-associated bloodstream prevention bundle appear to be equally promising.

“Wide implementation of [AHRQ’s] strategies would save tens of thousands of lives each year,” Dr. Brady said.

Barriers to improving patient safety may include failure of health systems to implement complex, behavior-based interventions, as influenced by organizational leadership and culture. Dr. Brady recommends additional research in this area.

“An additional challenge to the successful implementation of safety strategies at individual hospitals may be the increasingly long list of ideas to improve patient safety,” Dr. Brady noted. “As this field has no shortage of good ideas, it may be challenging for hospital boards and patient safety leaders to determine where to focus. This rigorously developed, evidence-based top 10 is an important step to help healthcare administrators, clinicians, and researchers best target their efforts to improve patient safety now.”

“Fundamentally, we need to know more about what causes harm to patients and which strategies are effective in preventing them,” Foster concluded.

The AHRQ supported development of their report. Dr. Brady and Foster have disclosed no relevant financial relationships. Some of the report and editorial authors have disclosures involving the National Institutes of Health Research Collaborations for Leadership in Applied Health Research and Care for Birmingham and the Black Country; ECRI Institute; Veterans Affairs; AHRQ; Centers for Medicare & Medicaid Services; National Institute of Nursing Research, Office of the National Coordinator; UpToDate; Cantel Medical Group; Association for Professionals in Infection Control and Epidemiology, Hospitals and Health Care Systems; National Institutes of Health; Leigh Bureau; Penguin Group; American Board of Internal Medicine, Salem Hospital; Lippincott, Williams & Wilkins, McGraw-Hill; QuantiaMD; PatientSafe Solutions, CRISI, EarlySense; John Wiley and Sons; Marc and Lynne Benioff; United States–United Kingdom Fulbright Commission; RAND Corporation; and/or more than 100 other healthcare organizations including hospitals, healthcare systems, and state medical and hospital associations. Full conflict-of-interest information is available on the journal’s Web site.

Annals Intern Med. Published online March 4, 2013.

Reducing medical errors: What we can learn from the Dreamliner @Medici_Manager @kevinmd

 | POLICY | MARCH 9, 2013

If you think that medical errors are a thing of the past, you are mistaken.

It has been 14 years since the Institute of Medicine’s report “To Err Is Human” shattered the myth that most, if not all, physicians are all-knowing practitioners with flawless skills and infallible judgment.

The story of what happened in the report’s wake was predictable:

  • Where the healthcare industry failed to act as it should have, the federal government and accrediting organizations stepped in to set the standards for healthcare quality and safety, establish quality measures, and assure that healthcare delivery entities complied by instituting financial and other penalties for poor performance.
  • Patients who previously felt safe began to question their healthcare providers.
  • We began to see some evidence of improvement in the quality and safety of healthcare services across the U.S.

In light of the foregoing, a recent “trip” to the website for American Medical News, the newspaper of the American Medical Association, left me feeling frustrated and sad.

story by Kevin B. O’Reilly referred to a recent well-referenced article in Surgery, noting that, at the close of last year, “never events” continue to occur in U.S. operating rooms 80 times per week.

In addition to causing temporary or permanent harm to patients, he extrapolated that these events carry a financial burden of almost $1.3 billion over 20 years.

Although surgical “never events” are rare (i.e., one in every ~12,000 procedures), their seriousness should not be diminished — especially when simple checklists and protocols have been shown to reduce the occurrence of such mistakes to near zero.

According to the article, published findings of a review of medical liability settlements and judgments collected in the National Practitioner Data Bank for 1990 to 2010 revealed that surgeons of all ages are involved in “never events” such as inadvertently leaving surgical items in the patient, performing either the wrong procedure or the right procedure on the wrong site, and — most egregious of all — operating on the wrong patient.

Startling as this is, previous studies have found that the 90% of injured patients who do not receive indemnity payments are not even included in the data bank.

Other studies have shown that “never events” can be eliminated — or at least minimized — by intensifying focus on identifying and correcting deficient processes, for example by addressing communication lapses with presurgery briefings and marking operative sites.

To its credit, the Joint Commission’s Center for Transforming Healthcare launched a project in 2010 to reduce wrong-site surgery risk at eight healthcare organizations and to provide tools to help others prevent these mistakes.

After these organizations reduced the proportion of cases in which there was a process-related problem that could have resulted in a wrong-site surgery from 52% to 19%, the commission made a wrong-site surgery prevention toolkit available to its accredited hospitals at no cost.

A national surgical safety project — NoThing Left Behind — introduced a slight change in the process for counting sponges at the end of procedures and some organizations have adopted new technologies (e.g., bar-coded sponges) to address the problem of retained foreign bodies.

Despite these and other evidence-based efforts, surgical “never events” continue to occur at the rate of 4,160 every year.

Because patient safety is part and parcel of my daily routine — whether in the hospital, the classroom, or at a national meeting — I ask myself why our industry is not mortified and why, as a nation, we are not appalled.

When I look to the airline industry for analogies, as I often do, the Boeing 787 “Dreamliner” comes to mind.

After only a couple of incidents, the federal government grounded this newest, most technically sophisticated airliner until the problem was fully understood, the deficiency corrected, and the risk to passengers and crew minimized.

Shouldn’t we address surgical “never events”, which affect 4,160 patients each year, with the same urgency and gravity that we address the potential risk to 210-270 passengers of travelling in the “Dreamliner”?

David B. Nash is Founding Dean of the Jefferson School of Population Health at Thomas Jefferson University and blogs at Nash on Health Policy.

Patient Safety Programs Ineffective, Most Nurses Say @Medici_Manager

Alexandra Wilson Pecci, for HealthLeaders Media, March 12, 2013

Nurses see themselves as the gate-keepers of patient safety, but many believe that the culture inside their hospitals actually keeps them from achieving patient safety goals.

They say poor communication, ineffective programs, and punitive environments are hampering patient safety efforts.

Those are some of the findings from a survey of 900 practicing registered nurses by the ANA and GE Healthcare. The survey, which queried 500 nurses in the United States, 200 in the United Kingdom, and 200 in China, finds that few nurses would call their hospitals “safe.”

One of the most striking findings is the apparent chasm between the existence of hospital patient safety programs and their perceived effectiveness. For example, 94% of nurses surveyed say that their hospitals have programs in place that promote patient safety, which on the surface is great news; these programs are probably something that the execs at these institutions brag about.

However, nurses—90% of whom consider themselves most responsible for patient safety, over physicians (69%) and patient safety officers (60%)—don’t seem enthusiastic about the effectiveness of their hospital’s patient safety programs.

Only 41% of nurses describe the hospital they work in as “safe.” Just over half of nurses (57%) believe that the patient safety programs in their hospital are effective.

Whether these programs exist doesn’t seem to affect nurses’ perceptions of patient safety as much as the factors that affect how the programs are actually put in to practice. For example, in theory, patient safety programs might rely on error reporting and discussing these errors as a team.

In practice, however, error reporting often doesn’t occur because nurses are afraid they’ll be penalized for making mistakes. The survey found that although 90% of nurses say it’s important to have a culture where nurses are not penalized for reporting errors or near misses, 59% agree that nurses often hold back reporting patient errors in fear of punishment. Most nurses (62%) say the same about reporting near-misses.

Another key component of patient safety is open communication between nurses and their peers (and their leaders); nurses and physicians; and hospitals and patients.

But again, nurses identify a gap between theory and practice. Despite the prevalence of patient safety programs—and the communication that those programs presumably encourage—just 37% of nurses rated their hospital as excellent at communication with the patient. Even fewer nurses (31%) say their hospital is excellent at communication between staff.

For example, 33% of nurses said that that “poor communication among nurses at handoff” is something that has increased the risk of patient safety incidences in their hospital in the past 12 months, and 31% said “poor communication with doctors” has also increased the risk of patient safety incidents.

Another area where nurses crave more communication is technology. The survey finds that 74% of nurses say that technology/software patient safety initiatives exist in their hospitals. Although 59% of nurses say that patient safety data is collected and reported, they also say that there’s no follow-up or feedback given to the nurses.

Taken as a whole, these results seem to indicate that nurse leaders need to make a greater effort to really engage bedside nurses in patient safety initiatives, from development to implementation. Nurse leaders and executives should remember what Carolyn C. Scott, RN, M.Ed, MHA, vice president of performance improvement/quality for the Premier Healthcare Alliance, told me recently:

“There’re some incredibly creative and innovative bedside nurses in each and every organization. I’m always amazed at the ideas and the strategies that they’re even able to bring forward themselves; how to make something better.”

Alexandra Wilson Pecci is a managing editor for HealthLeaders Media.

Incidentalomas: The real cost of ordering tests @Medici_Manager @SIHTA_Italia @kevinmd


I recently read a very good article in the New York Times about a patient found to have the classic incidentaloma, a small mass in the adrenal gland.  This is estimated to be seen in 4% of abdominal CT scans, and is rarely serious but typically leads to recommendations for additional testing and follow up CT scans to assure that it is not either a metastatic cancer from another area or a hormone secreting tumor of the adrenal gland itself. It is so common that the NIH has a formal recommendation article to guide physicians on how to manage a small adrenal mass found on imaging modalities, what they refer to as adrenal incidentaloma, and even have an acronym “AI.”

The term incidentaloma is a tongue-in-cheek to denote an incidental finding on an imaging test.  –oma is the suffix used in the name of any tumor or enlargement.  Examples are lipoma, condyloma, meningioma, teratoma, and dozens of others. The root of the term obviously refers to the fact that it was an incidental finding on a test looking for something else altogether.

Classic incidentalomas include:

  • Tiny solitary pulmonary nodules. Commonly on chest x-ray or chest CT scan a small pulmonary nodule is seen.  Most times these are the result of a prior fungal infection or previous inflammation, but often require follow up imaging.
  • Small ovarian cysts seen on pelvic ultrasound.  The ovaries of women of child bearing age form an ovulatory cyst each month, and commonly these normal cysts, or other small cysts of questionable importance are noted on pelvic ultrasounds done for evaluation of uterine fibroids, evaluation of abnormal bleeding, or other concerns where ovarian cyst or cancer is not the primary concern.  Follow up ultrasounds, occasional surgery, and lots of emotional angst are the most common outcomes.
  • Renal cysts. Abdominal CT scans often show “lesions” in the kidney that require further evaluation to determine if they are simple renal cysts or possibly solid tumors.  They usually are cysts, but are common incidental findings on CT scans done to look for kidney stones, diverticulitis, or other problems. Again additional evaluation with ultrasound and sometimes monitoring over time or even biopsy are done to further evaluate these incidentalomas.
  • Lab test abnormalities, though not referred to as incidentalomas are other common incidental findings that often lead to a cascade of follow up testing.  The most common example in my practice is minor elevation of liver enzymes called transaminases, or liver function tests.  When abnormal these are usually repeated along with testing for viral hepatitis C and B.  If they remain abnormal liver imaging, sometimes liver biopsy are often done.  The usual outcome is a diagnosis of fatty liver, with advice to stop drinking alcohol, and lose weight.  This is advice that could have been given without even knowing the liver enzymes were elevated.

The whole incidentaloma problem is just one example of the real cost of ordering tests, especially tests like CT scans and MRIs that are so sensitive that they often find insignificant minor abnormalities or normal variants that lead to yet more expensive and sometimes invasive evaluation.

Edward Pullen is a family physician who blogs at

Lessons Learned from Aviation Can Bring Remedies to Patient Safety @Medici_Manager @pash22

In commercial aviation, the last passenger fatality on a large U.S. jet was more than a decade ago. In health care, there may be as many as 200,000 preventable deaths each year in this country alone. We must stop thinking of these as unavoidable, and instead think of them as unimaginable.

By Chesley “Sully” Sullenberger III

Sully Sullenberger

Long before I became known for the Hudson River landing of US Airways Flight 1549, I had spent my professional life becoming expert at the science of safety. Decades in the cockpit, combined with years of airline safety work as an accident investigator and an airline crew instructor, taught me that good outcomes are the result of reliable systems, good leadership, consistent use of best practices, clear communication – and years of preparation. It doesn’t matter if your domain is the cockpit or the operating room: safety requires a system and a culture that must be learned and practiced by every member of the team. And that is why I so strongly believe that there is much our health care system can learn from the impressive system and culture of safety that have been  developed in the airline industry.

How can two seemingly disparate worlds be connected? Consider that aviation and health care are both high-risk, complex, evidence-based domains that require high-level human performance. Now contrast the safety records of these two fields.  In commercial aviation, the last passenger fatality on a large U.S. jet was in November 2001, more than a decade ago. Not so in health care. As we know from the Institute of Medicine reports and others, there may be as many as 200,000 preventable deaths each year in this country alone, including deaths resulting from what are considered to be medical errors – but are really system failures – and health-care-associated conditions. That’s the equivalent of 20 large jetliners crashing a week with no survivors, nearly 3 a day. After about the second day, we would see what we had after September 11, 2001 – a nationwide ground stop. There would be a Presidential commission, Congressional hearings; the National Transportation Safety Board (NTSB) would search out causes. No one would fly until we had solved the problems. Because airline accidents are very rare, they involve many people at once, they are noteworthy and newsworthy, we have achieved in aviation the public awareness and the political will to act. And that’s what’s lacking currently in medicine, along with leadership and direction, and a real sense of urgency, to address a problem that is systemic, huge and immediate.  There are many who still think of these deaths as an unavoidable consequence of providing care.  We must stop thinking of them as unavoidable, and instead think of them as unimaginable.

One remedy would be the establishment of an entity like the NTSB to investigate select, representative medical failures. (See An NTSB for Health Care — Learning From Innovation: Debate and Innovate or Capitulate).  This, I believe, would help move medicine from the current blame-based system to a learning-based system in which accountability and learning are fairly and accurately balanced, and people feel free to report not only their own mistakes but system deficiencies that might lead to an accident. Through the NTSB the aviation industry has a formal lessons learned process. It comes up with probable causes and contributing factors. It makes recommendations to the rule makers and the industry about how to prevent a recurrence. This information is globally disseminated, but locally actionable.

Another remedy is to change the culture involving what I call human skills. In the old days of aviation, captains could be gods and cowboys. They often ruled their cockpits by whim, according to idiosyncrasies and preferences, with little consideration of best practices. If someone spoke to a captain about an unsafe practice, they put their jobs on the line. Thankfully, those days are long gone. We have achieved much better standardization; we have taught captains that they have to be the builders and leaders of teams; we set the tone, we create an environment of psychological safety, where there are no stupid questions, where we create a shared sense of responsibility for the outcome. It’s not about who’s right, it’s about what’s right. And paradoxically, it’s this reliability, this standardization of processes that becomes the firm base on which we can innovate when we face the unexpected. That’s what my crew and I did on Flight 1549. This was something we never trained for, it was something we had never envisioned, and we had 208 seconds to solve this life-threatening problem we had never seen before.

For more than a hundred years now, we have been learning important lessons at great cost, many of them literally bought in blood. Almost everything we know in aviation, every procedure, every rule, we have because people have died. All these lessons that have finally made aviation so ultra-safe, we are now offering up to medicine for the taking.

What would it take for health care systems to adopt some of the practices of aviation? If there were a national reporting agency for medical errors and near misses, would you be more likely to report? Tell us what you think in the Comment box below.

Best known as the hero pilot from the “Miracle on the Hudson,” Chesley B. “Sully” Sullenberger III has been dedicated to the pursuit of safety for his entire adult life. An aviation safety expert and accident investigator, Mr. Sullenberger serves as a CBS News Aviation and Safety Expert, as well as founder and chief executive officer of Safety Reliability Methods, Inc.,  a company dedicated to management, safety, performance, and reliability consulting. He is also on the editorial board of the Journal of Patient Safety and a member of the Greenlight Group, a team of world class experts supporting a number of global health care research and development initiatives.

Readmissions and mortality @Medici_Manager @IncidentalEcon


Much has been made about the relationship between hospital readmission rates and mortality. Dead people can’t be readmitted, suggesting a negative correlation. On the other hand, decreases in both seem to be measures of quality, suggesting a positive correlation.

Harlan Krumholz and colleagues published a JAMA article last month that examines the correlation between risk-adjusted, 30-day readmission rates and mortality rates, both calculated on a fee-for-service Medicare cohort using CMS’s methodology. In particular, they examined patients discharged with a diagnosis of heart failure (HF), acute myocardial infarction (AMI), or pneumonia (PN). Correlations were not statistically significantly different from zero between mortality and readmission rates for the AMI and PN disease cohorts. For the HF cohort, the correlation point estimate was -0.17. Wanna see it?

readmit mort HF

(Dashed lines are medians. The blue line is a cubic spline smooth regression. The shaded area designates the 95% confidence interval.)

The authors conclude that mortality and readmission rates measure different, nearly orthogonal aspects of quality.

From a policy perspective, the independence of the measures is important. A strong inverse relationship might have implied that institutions would need to choose which measure to address. Our findings indicate that many institutions do well on mortality and readmission and that performance on one does not dictate performance on the other.

Ashish Jha has another perspective. A quote doesn’t do justice to his argument, but here’s the key passage:

So if one measure of quality is external validity – being at least somewhat correlated with the gold standard (mortality rates) — how does the readmission measure do? In a paper published recently in JAMA, we see that readmission rates don’t do so well at all. Readmission rates are un-correlated with mortality rates. In fact, for one of the three conditions, the readmission rate seems to go the wrong way: the best hospitals for heart failure (i.e. those with the lowest mortality rates) have readmission rates that are actually higher. Not perfect. Readmissions seem to have little external validity as a quality measure. Readmissions are, however, correlated with two things: how sick your patients are, and how poor your patients are. We now have good data that the Hospital Readmission Reduction Program disproportionately penalizes big academic teaching hospitals (that care for the sickest patients) and safety-net hospitals (that care for the poorest).

Ashish goes on to suggest readmission rates can still play a helpful role in motivating hospitals and health systems to improve. Maybe! I worry that they can also be gamed. Since they’re hardly correlated with mortality, we may not easily detect when they are.


The Cochrane Reviews highlighted here are freely available while this Special Collection is featured on The Cochrane Library homepage.


The International Labour Organisation celebrates the World day for Safety and Health at Work on the 28th of April, with a theme for 2013 of prevention of occupational diseases ( Labour unions worldwide also commemorate workers who have died at work or as a result of exposure at work on this day.

Fortunately, many statistics indicate that workplace health and safety have improved over time. Occupational injury rates in the US show a steady decline over the past 100 years, and exposure to chemical agents in the US and Europe has also decreased considerably in the past forty odd years.[1] However, uncertainty about what specific interventions led to these improvements makes it difficult to select appropriate interventions in countries where rates remain high. Moreover, there are still occupational health statistics that are not favourable at all. Noise-induced hearing loss, work-related musculoskeletal disorders, stress-related complaints and skin disorders remain very prevalent. Other less prevalent conditions (for example HIV and Hepatitis C) have extremely serious consequences, and so protecting workers from these risks remains a high priority.

The Cochrane Occupational Safety & Health Review Group has selected a number of recent Cochrane Reviews that explore the evidence for interventions aimed at preventing occupational diseases. These can be used by employers to develop preventive policy and practice and achieve tangible health benefits for their employees.

[1] Creely KS, Cowie H, Van TM, Kromhout H, Tickner J, Cherrie JW. Trends in inhalation exposure–a review of the data in the published scientific literature. Ann Occup Hyg 2007;51(8):665-78.


Antibiotic prophylaxis for leptospirosis
Leptospira infection is a global zoonosis with significant health impact for agricultural workers and those persons whose work or recreation takes them into endemic areas. This systematic review assessed the current literature for evidence for or against use of antibiotic prophylaxis against Leptospira infection (leptospirosis).

Antibiotic prophylaxis for mammalian bites
Bites by mammals are a common problem and they account for up to 1% of all visits to hospital emergency rooms. Dog and cat bites are the most common and people are usually bitten by their own pets or by an animal known to them. School-age children make up almost a half of those bitten. Prevention of tetanus, rabies and wound infection are the priorities for staff in emergency rooms. The use of antibiotics may be useful to reduce the risk of developing a wound infection. This systematic review aimed to determine if the use of prophylactic antibiotics in mammalian bites is effective in preventing bite wound infection.

Antiretroviral post-exposure prophylaxis (PEP) for occupational HIV exposure
Populations such as healthcare workers (HCWs), injection drug users (IDUs), and people engaging in unprotected sex are all at risk of being infected with the human immunodeficiency virus (HIV). Animal models show that after initial exposure, HIV replicates within dendritic cells of the skin and mucosa before spreading through lymphatic vessels and developing into a systemic infection (CDC 2001). This delay in systemic spread leaves a “window of opportunity” for post-exposure prophylaxis (PEP) using antiretroviral drugs designed to block replication of HIV (CDC 2001). PEP aims to inhibit the replication of the initial inoculum of virus and thereby prevent establishment of chronic HIV infection. This systematic review aimed to evaluate the effects of antiretroviral PEP post-occupational exposure to HIV.

Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in high-income countries
Interventions to change behaviour among sex workers and their clients have been identified as a strategy to reduce HIV transmission. However, there has been no systematic review that has examined and summarized their effects. This systematic review aimed to identify and evaluate the effects of the studies performed on behavioural interventions to reduce the transmission of HIV infection among sex workers and their clients in high-income countries.

Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Various interventions have been adopted to reduce HIV transmission among sex workers and their clients but the effectiveness of these strategies has yet to be investigated using meta-analytic techniques. This systematic review aimed to evaluate the effectiveness of behavioural interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries.

Blunt versus sharp suture needles for preventing percutaneous exposure incidents in surgical staff
Surgeons and their assistants are especially at risk of exposure to blood due to glove perforations and needle stick injuries during operations. The use of blunt needles can reduce this risk because they don’t penetrate skin easily but still perform sufficiently in other tissues. This systematic review aimed to determine the effectiveness of blunt needles compared to sharp needles for preventing percutaneous exposure incidents among surgical staff.

Influenza vaccination for healthcare workers who work with the elderly
Healthcare workers’ (HCWs) influenza rates are unknown, but may be similar to the general public and they may transmit influenza to patients. This systematic review aimed to identify studies of vaccinating HCWs and the incidence of influenza, its complications and influenza-like illness (ILI) in individuals aged ≥60 years in long-term care facilities (LTCFs).

Vaccines for preventing hepatitis B in health-care workers
Hepatitis B virus (HBV) causes acute and chronic liver diseases. Hepatitis B vaccination is recommended for health-care workers. This systematic review aimed to assess the beneficial and harmful effects of hepatitis B vaccination in health-care workers.


Preventing occupational stress in healthcare workers
Healthcare workers can suffer from occupational stress which may lead to serious mental and physical health problems. This systematic review aimed to evaluate the effectiveness of work and person-directed interventions in preventing stress at work in healthcare workers.

Preventive staff-support interventions for health workers
Healthcare workers need to be supported to maintain sufficient levels of motivation and productivity, and to prevent the debilitating effects of stress on mental and physical well-being. This systematic review aimed to assess the effects of preventive staff-support interventions to healthcare workers.

Psychological debriefing for preventing post traumatic stress disorder (PTSD)
Over approximately the last fifteen years, early psychological interventions, such as psychological ‘debriefing’, have been increasingly used following psychological trauma. Whilst this intervention has become popular and its use has spread to several settings, empirical evidence for its efficacy is noticeably lacking. This systematic review aimed to assess the effectiveness of brief psychological debriefing for the management of psychological distress after trauma, and the prevention of post traumatic stress disorder.

Psychosocial interventions for prevention of psychological disorders in law enforcement officers
Psychosocial interventions are widely used for the prevention of psychological disorders in law enforcement officers. This systematic review aimed to assess the effectiveness and comparative effectiveness of psychosocial interventions for the prevention of psychological disorders in law enforcement officers.


Interventions to prevent occupational noise-induced hearing loss
Millions of workers worldwide are exposed to noise levels that increase their risk of hearing impairment. Little is known about the effectiveness of hearing loss prevention interventions. This systematic review aimed to assess the effectiveness of non-pharmaceutical interventions for preventing occupational noise exposure or occupational hearing loss compared to no intervention or alternative interventions.

Interventions to promote the wearing of hearing protection
Noise-induced hearing loss can be prevented by eliminating or lowering noise exposure levels. Where the source of the noise cannot be eliminated, workers have to rely on hearing protection equipment. Several trials have been conducted to study the effectiveness of interventions to influence the wearing of hearing protection. This systematic review aimed to evaluate the effectiveness of interventions to enhance the wearing of hearing protection among persons regularly exposed to high noise levels.


Non-pharmacological interventions for preventing venous insufficiency in a standing worker population
Chronic venous insufficiency (CVI) is a common problem, affecting up to 50% of the population in industrialised countries. It is a chronic condition which, if untreated, can progress to serious complications that in turn can interfere with working ability. Standing at work is a known risk factor for CVI, yet the true effect of non-pharmacological preventive strategies remains unknown. This systematic review aimed to evaluate the efficacy of non-pharmacological strategies and devices to prevent CVI in a standing worker population.


Interventions for preventing voice disorders in adults
Poor voice quality due to a voice disorder can lead to a reduced quality of life. In occupations where voice use is substantial it can lead to periods of absence from work. This systematic review aimed to evaluate the effectiveness of interventions to prevent voice disorders in adults.

Remediating buildings damaged by dampness and mould for preventing or reducing respiratory tract symptoms, infections and asthma
Dampness and mould in buildings have been associated with adverse respiratory symptoms, asthma and respiratory infections of inhabitants. Moisture damage is a very common problem in private houses, workplaces and public buildings such as schools. This systematic review aimed to determine the effectiveness of remediating buildings damaged by dampness and mould in order to reduce or prevent respiratory tract symptoms, infections and symptoms of asthma.


Interventions for preventing occupational irritant hand dermatitis
Occupational irritant hand dermatitis (OIHD) is an important cause of discomfort in the working population. Different preventive measures are in place but it is not clear how effective these are. This systematic review aimed to assess the effect of interventions for preventing OIHD in healthy people who work in occupations where the skin is at risk of damage.


Ergonomic design and training for preventing work-related musculoskeletal disorders of the upper limb and neck in adults
Work-related upper limb and neck musculoskeletal disorders (MSDs) are one of the most common occupational disorders around the world. Although ergonomic design and training are likely to reduce the risk of workers developing work-related upper limb and neck MSDs, the evidence is unclear. This systematic review aimed to assess the effects of workplace ergonomic design or training interventions, or both, for the prevention of work-related upper limb and neck MSDs in adults.

Exercises for prevention of recurrences of low-back pain
Back pain is a common disorder that has a tendency to recur. It is unclear if exercises, either as part of treatment or as a post-treatment programme, can reduce back pain recurrences. This systematic review aimed to investigate the effectiveness of exercises for preventing new episodes of low-back pain or low-back pain-associated disability.

Insoles for prevention and treatment of back pain
There is lack of theoretical and clinical knowledge of the use of insoles for prevention or treatment of back pain. The high incidence of back pain and the popularity of shoe insoles call for a systematic review of this practice. This systematic review aimed to determine the effectiveness of shoe insoles in the prevention and treatment of non-specific back pain compared to placebo, no intervention, or other interventions.

Lumbar supports for prevention and treatment of low back pain
Lumbar supports are used in the treatment of low-back pain patients, to prevent the onset of low-back pain (primary prevention) or to prevent recurrences of a low-back pain episode (secondary prevention). This systematic review aimed to assess the effects of lumbar supports for prevention and treatment of non-specific low-back pain.

Manual material handling advice and assistive devices for preventing and treating back pain in workers
Training and the provision of assistive devices are considered major interventions to prevent back pain and its related disability among workers exposed to manual material handling (MMH). This systematic review aimed to determine the effectiveness of MMH advice and training and the provision of assistive devices in preventing and treating back pain.


Pre-employment examinations for preventing occupational injury and disease in workers
Many employers and other stakeholders believe that health examinations of job applicants prevent occupational diseases and sickness absence. This systematic review aimed to evaluate the effectiveness of pre-employment examinations of job applicants in preventing occupational injury, disease and sickness absence compared to no intervention or alternative interventions.

Acknowledgements: Jos Verbeek, Thais Morata and Jani Ruotsalainen from the Cochrane Occupational Safety & Health Review Group for drafting the introductory text, providing the image, comments and edits, and for selecting the reviews included in this special collection.

Image credit: Iisakki Härmä

Date published: 22 April 2013

Contact: Cochrane Editorial Unit (

Antimicrobial resistance—an unfolding catastrophe @Medici_Manager @bmj_latest

Fiona Godlee, editor, BMJ

At the end of the 1960s, the then US surgeon general William H Steward famously declared: “The war against infectious diseases has been won.” His optimism might well have been justified at the time. The discovery of antibiotics and their widespread introduction had transformed both medical practice and life expectancy.

Antibiotics still transform lives, but—as with so many of the world’s resources—we now know that they are not limitless, and that unless we are careful, their beneficial effects will run out. We have become so accustomed to the availability of antibiotics that a world without them is almost inconceivable. Yet this is the world that England’s chief medical officer, Sally Davies, demands we contemplate in the second volume of her annual report (doi:10.1136/bmj.f1597). The causes of this unfolding catastrophe are many: overuse of existing antibiotics, increasing resistance to them, a “discovery void” regarding new drugs, and a change in the types of organisms presenting the greatest threat. “If we don’t get this right we will find ourselves in a health system not dissimilar to the early 19th century,” she says.

Is Davies being overdramatic? Sadly not. Her decision to focus on antimicrobial resistance has been broadly welcomed. And this week we publish a report from Richard Smith and Joanna Coast, long term analysts of the economics of resistance (doi:10.1136/bmj.f1493). They suggest that the picture she paints may even be too rosy. “Resistance is said to present a risk that we will fall back into the pre-antibiotic era,” they say. “However, this is perhaps optimistic.”

Their argument is that we have badly underestimated the cost of resistance. Studies that have tried to estimate the economic impact have looked at the extra cost of treating a resistant infection compared with a susceptible one. But this ignores the bigger picture. The whole of modern healthcare, including invasive surgery and immunosuppressive chemotherapy, is based on the assumption that infections can be prevented or treated. ”Resistance is not just an infectious disease issue,” they say. “It is a surgical issue, a cancer issue, a health system issue.”

Their revised assessment of the economic burden of resistance encompasses the possibility of not having any effective antimicrobial drugs. Under these circumstances they estimate that infection rates after hip replacement would increase from about 1% to 40-50%, and that about a third of people with an infection would die. It seems likely that rates of hip replacement would fall, bringing an increased burden of morbidity from hip pain.

The CMO’s 17 recommendations include better hygiene measures and surveillance, greater efforts to preserve the effectiveness of existing drugs, and encouragement to develop new ones. As Anthony Kessel and Mike Sharland point out, only one or two new antibiotics that target Gram negative organisms are likely to be marketed in the next decade (doi:10.1136/bmj.f1601). Recognising this as a global problem, the CMO’s report also calls for antimicrobial resistance to be put on the national risk register and taken seriously by politicians internationally.

As for the cost of such action, Smith and Coast see it as an essential insurance policy against a catastrophe that we hope will never happen. And they share the CMO’s urgency. “Waiting for the burden to become substantial before taking action may mean waiting until it is too late.”


Cite this as: BMJ 2013;346:f1663

Footnotes Follow BMJ Editor Fiona Godlee on Twitter @fgodlee and the BMJ @bmj_latest

Migliorare la sicurezza dei pazienti: ecco la top ten @GIMBE @Medici_Manager

dal blog di Nino Cartabellotta

Oggi gli Annals of Internal Medicine hanno pubblicatoMaking Health Care Safer, numero monografico che raccoglie numerose revisioni sistematiche sull’efficacia delle strategie per migliorare la sicurezza dei pazienti.

Dopo avere valutato quantità e qualità delle evidenze disponibili, nell’articolo di apertura Paul Shekelle et coll. identificano 22 strategie per la sicurezza dei pazienti, di cui 10 vengono fortemente raccomandate.

Ecco l’elenco degli interventi che organizzazioni sanitarie e professionisti devono urgentemente implementare in maniera sistematica:

  • Checklist pre-operatorie e anestesiologiche per prevenire eventi avversi peri-e post-operatori
  • Pacchetti che includono checklist per prevenire le infezioni sistemiche CVC-correlate
  • Interventi per ridurre l’utilizzo del catetere vescicale: reminder, stop orders, protocolli di rimozione a gestione infermieristica
  • Pacchetti per la prevenzione della polmonite da ventilazione meccanica che includono: sollevamento della testata del letto, interruzioni della sedazione, igiene orale con clorexidina, tubi endotracheali per l’aspirazione subglottica
  • Igiene delle mani
  • Predisporre un elenco di abbreviazioni pericolose da non usare
  • Interventi multifattoriali per ridurre le lesioni da decubito
  • Precauzioni barriera per prevenire le infezioni associate all’assistenza
  • Utilizzo dell’ecografia in tempo reale per il posizionamento delle vie centrali
  • Interventi per migliorare la profilassi del tromboembolismo venoso

Curioso osservare come la quasi totalità degli interventi coinvolga prevalentemente il personale infermieristico: e intanto, davanti all’indiscutibile rilevanza di tale professione per migliorare la sicurezza dei pazienti, in Italia si continua a discutere delle autonomie professionali degli infermieri…

FonteShekelle PG, et al. The top patient safety strategies that can be encouraged for adoption now. Ann Intern Mer 2013;158:365-368