Comments on: Reducing Bloodstream Infections

By: Kim

Kim — Sat, 24 Sep 2011 03:45:23 +0000

My Mom god a blood infection at Upmc Shadyside. Her kidneys failed as a result and she died. I suspected if came from tthe catheter but they denied it. However they couldn’t tell me where it originated other than it did start in the hospital. My Mom didn’t have to die that way. I begged them not to put the catheter in and to take it out after a maximum of three days. They refused. They also made her do her bowel movements in the bed and it mixed with the urine. They disregarded human decency as well as safe practices.

By: Healthcare Update — 11-19-2010 | WhiteCoat's Call Room

Healthcare Update — 11-19-2010 | WhiteCoat's Call Room — Sat, 20 Nov 2010 14:39:44 +0000

[...] methods were standardized. The researchers could have saved their troubles by looking at some real investigative blogging on the [...]

By: ERDocDFW

ERDocDFW — Fri, 26 Feb 2010 19:17:10 +0000

Perhaps if taxpayers started calling misappropriation of taxdollars a “never event” and refused to pay taxes if this occurred, the politicians in D.C. would shape up a little bit…..
Of all the nonsense I’ve heard over the years, “never event” is up there pretty high.

By: Anonymous

Anonymous — Thu, 25 Feb 2010 18:12:47 +0000

Just to comment on the first part: it’s illegal to cut through parking lots and private property to bypass a traffic signal.

By: DreamingTree

DreamingTree — Tue, 23 Feb 2010 13:19:52 +0000

I find this to be incredibly frustrating. Patient mortality is directly related to staffing. Call it anything you want, choose any variable, but it all comes back to staffing. Poor staffing makes it less likely that nurses follow good infection control procedures. It also increases med errors, patient falls, & skin breakdown; it decreases response times for critical status changes.

Remember – KEEP IT SIMPLE STUPID! Instead, we study all of the variables related to patient deaths. We form committees to figure out ways to improve staff compliance with basic procedures. The solution? More forms, more work to prove that we really do provide good patient care. No, we don’t. We don’t have enough staff to provide good patient care. And, the staff that we have are getting burned out from the amount of work and frustrated by the increasing amount of paperwork. Most of these problems could be solved by simply hiring & retaining enough RN’s & aides.

Sigh…rant over…

By: brett

brett — Tue, 23 Feb 2010 03:52:04 +0000

Fantastic post. I with the dimwitted CMS could understand it.

By: Vince

Vince — Tue, 23 Feb 2010 03:06:59 +0000

I’ve always had similar questions regarding the reporting of never events. Things that sound too good to be true usually are, and all these hospitals reporting zero central or urinary catheter related infections after having dozens or hundreds during an equal time period sounds way too perfect to me. Don’t even get me started on all the unnecessary antibiotics given to fit the 4hr pneumonia window (personal peeve of mine). Like you, I praise Dr. Pronovost’s system and am happy for the support it has (often begrudgingly) earned over the years, but its bastardization by those outside of healthcare will minimize its effectiveness. Doctors who didn’t even want to implement it in the first place will wonder why they should bother to actually run through it when the numbers can be fudged regardless, and false numbers will foil any attempts to further refine the lists or develop new ones.

Thank you for such a well thought out and researched post, hopefully more outspoken doctors like you will get noticed in the coming months/years.

By: Ozzy

Ozzy — Tue, 23 Feb 2010 01:33:22 +0000

Hey WC, great post.
I wonder if you’re familiar with or read Atul Gawande’s new book – ‘The Checklist Manifesto’, which addresses the use of checklists to avoid errors and what impact they have on our society. I believe that the existence of ‘never events’ is absurd and they’re inevitable in the current healthcare settings. I think that errors can be avoided with checklists, but when the insurance industry and CMS tie them in with ‘pay for performance’ – we lose sight of the end point – which is better patient care, and not money saving.
As a result you have Consumer Reports reporting unreliable data, pleasing the government and the general public, but in the process, doing us (healthcare providers) all a huge disservice. The downward spiral continues.

By: Steve

Steve — Mon, 22 Feb 2010 22:42:59 +0000

Wow…way to go WC! That was a pretty amazing investigate post- I wouldn’t be surprised if someone starts taking a harder look at UPMCs data after this post.

I’ve always wondered myself how to define central line infections based on all the reasons you listed. If it’s so hard to define, it probably shouldn’t be a “never” event or you’ll get the data massaging that may be present in these data sets. It’s pretty easy to define a wrong site/wrong patient surgery- not so easy when it comes to central line infections!

By: DensityDuck

DensityDuck — Mon, 22 Feb 2010 19:14:37 +0000

Any software-house manager knows that paying a reward for “bug found and corrected” means that you’ll have the buggiest product that anyone ever saw…