Archive for the ‘Joint Commission’ Category
Wednesday, December 30th, 2009
Our hospital created new order sets to be compliant with all of the new JCAHO patient safety mandates.
One of the JCAHO requirements is that pain medications must be administered according to a patient’s rated pain scale. If a patient complains of pain of “3″ they get one medication whereas if they complain of pain of “7″ they may need another medication.
So the order for pain medications on the order set reads “Administer [chosen pain medication] [chosen dosage] intramuscularly/intravenously every ___ hours for pain rated as _______.”
While writing admission orders for a patient, I just decided to write “administer morphine 5mg intravenously every 4 hours for pain rated as 2.17 or greater.”
The patient went upstairs to the floor. I forgot about her amongst the multiple other admits throughout the evening.
The following morning as my shift was ending, I get a visit from the president of the medical staff.
“You know that patient you sent upstairs last night … Mrs. Smith?”
Those are words that usually mean something bad happened.
“Yeah …” I said hesitantly.
“Well there was a big problem with her orders.”
“Like …?”
“What’s with the pain rating of ’2.17′? The secretary didn’t know how to enter it into the system. She called the nurse. The nurse didn’t know how to interpret it. She called the nursing supervisor. The supervisor had never seen someone enter a pain scale like that, so she called me – the attending – at 4 AM to clarify your order.”
“You’re kidding me.”
“No. But I kind of laughed, though. I’m actually surprised that no one has done that before. I just wanted you to know that you had the whole medical floor up in arms with that order.”
“Great. Sorry about that.”
Next time I’m going to write for medications when a patient rates their pain as “π” or above.
Then again, the symbol for “pi” looks too much like a Roman numeral “II” which could cause people to get pain medication when they rate their pain as a 2 instead of when they rate their pain as a 3.1415 or higher. That could result in patients getting pain medication for a rating 1.1415 points sooner than they actually need that pain medication and could compromise patient safety.
I will therefore write out the word “pi” when making this entry.
Then again, a sloppily written “pi” could look like the number “61″ which could make it so that some patient has to complain of pain of 61 or greater in order to receive pain medication. That could leave patients in pain and could compromise patient safety.
Or the “pi” could look like a “pl” which might be mistaken for a shorthand form of “please” so that a patient could be given pain medications for any pain rating in which they say “please.” That could result in overmedication and could compromise patient safety.
I think I see another patient safety mandate on the horizon.
Dang.
Posted in Joint Commission | 9 Comments »
Monday, July 6th, 2009
 I’m getting just about fed up with the Medical Marijuana Advocates (AKA “JCAHO”, AKA “TJC”) and this whole bunch of HospitalCompare.gov bullhokey.
The chart police at our hospital audited a bunch of charts from the emergency department and I got letters about several “serious offenses.”
First, I got in trouble because I couldn’t be credited with giving antibiotics within the 4 hour … no … now make that 6 hour window for a patient with pneumonia. For the moment forget about the fact that this quality indicator may do more harm than good. Forget that most pneumonias are viral and that requiring doctors to give antibiotics for these viral infections, similar to using Raid to kill dandelions, increases bacterial resistance and helps to spread MRSA. But I digress.
It wasn’t that the patient didn’t get timely antibiotics. The patient got antibiotics not within just 4 hours, but within 2 hours. By the way, congratulations on your increased chances of acquiring MRSA due to our government agency’s blind directives, sir.
It wasn’t that the patient didn’t get appropriate antibiotics. The patient had allergies to several medications (that were from 50 years ago when he was an infant, so he didn’t know what the reactions were), and given his history, we used clindamycin.
My serious offense was that CMS supposedly couldn’t tell what medication was ordered. Instead of writing out “clindamycin 300 milligrams piggyback through the intravenous line over 30 minutes,” the order said “clinda 300mg IVPB.” The nurse gave clindamycin 300 milligrams piggyback through the intravenous line over 30 minutes. But it was still considered poor quality care not because the patient didn’t receive his medication … not because the medication wasn’t given in a timely fashion … but because micromanaging government clipboard patrols with apparently little medical background couldn’t figure out what medication was ordered.
Fortunately for everyone involved, the ClindaCyanide and the ClindaDrano were on backorder in the pharmacy. Otherwise, the patient could have received some other dangerous medication beginning with “clinda” via his IV. Oh yeah, I forgot, there are no other medications beginning with “clinda” aside from clindamycin.
Just another reason why the whole HospitalCompare.org web site should be viewed with a healthy dose of skepticism. The statistics don’t necessarily tell you what they purport to tell you.
But that’s not all …
I also got dinged because I didn’t do one of the Medical Marijuana Advocates’ “time out” forms before doing a lumbar puncture and before draining an abscess.
“Time outs” are required before surgery so that surgeons don’t cut off the wrong appendage or do surgery on the wrong site. There are multiple requirements for a “time out” including preparing proper documentation (because that contributes so much to patient care), reviewing relevant images (if any), readying any necessary equipment, making an unambiguous mark near the procedure site with ink that will still be visible after any skin preparation (doctor’s initials are suggested), and double-checking the site mark before the procedure.
I’m not actually sure that these are the requirements, because I tried to look them up on the Medical Marijuana Advocates’ web site, but they keep the requirements hidden. Isn’t it great how an organization that is supposedly advocating for patient safety keeps all of its initiatives hidden from public view? But I digress yet again.
In theory, I don’t have any problems with marking the site to be operated on if a patient is going to be put under anesthesia prior to surgery and won’t be able to say “Hey doc, why are you starting to cut on my left leg when the abscess is on the right leg?” I’ll even go as far to say that the “time out” concept is a good idea under those circumstances.
But apparently the Medical Marijuana Advocates are now applying this “good” idea to areas where it does not belong and are now citing hospitals for compliance issues if there is not a “time out” form on file for every invasive procedure – even those done at the bedside. Of course I can’t find this on the TJC web site either. If this policy is true, it is asinine.
How exactly is it that I’m going to do a wrong site lumbar puncture? It’s not like I’m ruling out meningitis in many jellyfish. I haven’t had to rule out a subarachnoid hemorrhage in a Siamese twin lately. I don’t suffer from short term memory loss, so it’s not like I won’t remember the patient who just signed the consent form for me to do the procedure. Explain to me how drawing a circle and writing my initials on the back of a patient getting a lumbar puncture is going to improve patient safety.
Leg abscesses are just as bad. Good thing JCAHO is saving us from maiming people with abscesses in the emergency department. “Yeah, sir, that 10 cm abscess on your leg disappeared in the three minutes that elapsed between the point when I examined you and the point that I returned to the room after going to get a scalpel. Oh well, as long as you’re here, I guess I’ll just fillet open your thigh to look for ingrown hairs. Ooops! The abscess was on your other leg! Sorr-rry!”
If we’re going to do these forms on every invasive procedure, the lab is going to have a lot more work drawing blood. A spinal tap can be considered “drawing spinal fluid”, so drawing blood must also be an invasive procedure. Now doctors are going to have to be involved with every blood draw.
I’m most worried about a couple of other invasive procedures, though.
Not sure how the female patients are going to explain to their significant others how my initials got on their crotches if I have to do a pelvic exam.
And I could be wrong, but I don’t think that too many guys are going to let me draw a circle around their anus and put my initials there before I get out the glove and lube to do a prostate check.
Well … I’m going to go have a time out, write my initials on my right wrist, get all the proper equipment together (including a bottle and a frosted mug) and have 12 oz of ClindaBudweiser p.o. before I stroke out.
Posted in CMS, Joint Commission, Policy | 20 Comments »
Tuesday, February 3rd, 2009
One of the reasons our ED runs so smoothly is because we’re like a family. There’s very low turnover in our department and there’s a waiting list for nurses who want to work down here. I like to think it’s because of the high quality emergency physicians that work there. Everyone knows how everyone else works and a lot of things get done without anyone even having to ask. We know how to take advantage of each others’ strengths and doing so improves patient care.
Even though we’re a great team, just like a family, we pick on each other. My kids do it about their little idiosyncrasies – like purposely changing the TV channel just before Pokemon or Wow Wow Wubbzy comes on (actually I’ll change the channel myself just because I can’t stand that Wubbzy song).
One of the nurses has this habit of saying “or whatever” at the end of every one of his sentences. We razz him about that … or whatever. One secretary has been “going to quit” smoking for about 5 years. She catches flak about that every time she puts her coat on for a break. Another nurse has internal temperature regulation disorder and has to keep the temperature in the ED colder than a meat locker. So there are temperature wars with the thermometer.
Then there’s the nurse with partial accurate spelling disorder.
She’s kind of a recent grad, so she’s still learning the ropes. She has trouble spelling some medications and spelling some diagnoses we commonly use in the ED. She’s already learned not to ask me how to spell things because she never knows if I give her the right answer. Then she gets embarrassed and looks up the words in the medical dictionary. Then she gets ticked off when she can’t find them. Then she gets someone else to ask me how to spell something and hopes that I don’t realize that it is really her that wants to know how to spell it. Doesn’t work.
One of the multiple Medical Marijuana Advocates (my pet name for the “Joint Commission”) mandates for “patient safety” is that every time a patient comes to the emergency department, you have to write out a complete medication profile. Now I’m not actually sure that this is an actual Medical Marijuana Advocates mandate, but I can’t look it up online because the only way that you can find their mandates is to buy them. Getting sidetracked. Sorry. 
So the nurse with partial accurate spelling disorder picks up a patient with low risk chest pain, gets the history, and starts writing out a patient’s medication list. After she had finished, I grabbed the chart and went in to see the patient. The patient brought all of his pill bottles along, and one of them included the over-the-counter supplement at the right.
Only the pills at the right weren’t listed as being one of the medications he took.
Instead, the nurse had listed some other medication … “Flaccid Oil.”
Unfortunately, I can’t actually post a picture of the medication list the nurse had written out because when I walked out of the room laughing, she grabbed the list out of my hand and scribbled out what she had written – once she found out what I was laughing about.
But danged if, after checking the bottle, I didn’t have an itch on my arm. When I scratched my arm after handling the bottle, I must have gotten some pill residue on my arm and my arm went “flaccid.” Then I scratched my lip and my lip wouldn’t move. I started having slurred speech. The horror! What would I tell my wife if I had to go to the bathroom?
By the end of the day, most of the staff must have gotten Flaccid Oil residue on themselves because everyone seemed to have random episodes of periodic paralysis – arms, legs, necks – every time the nurse walked by. Man that stuff is hard to wipe off.
Yep. I love my job and I love the people I work with.
If you ever hear giggling in the ED when you’re a patient, chances are that it’s something like this.
Posted in Funny, Joint Commission | 8 Comments »
Wednesday, December 3rd, 2008
It’s funny how hospital operations change when the Medical Marijuana Advocates come by for an inspection.
Reminds me of our family getting ready to have holiday guests.
Secret phone calls go out to everyone. High alert. High alert.
Half-filled coffee mugs sitting on the counter mysteriously disappear.
Charge nurses run ahead of the group with a bunch of keys making sure every bit of medicine in the hospital is on lockdown.
Things that don’t have a place to go get thrown into a closet, the closet gets locked, and a sign gets put up saying “Bathroom – Out of Order.”
All the “procedure” books are prominently displayed.
Everyone acts busy.
Then a little group of people with suits, bright white lab coats and clipboards comes trotting through the ED. One of the hospital administrators is walking behind them frantically motioning to the ED tech to take the patient chart off the counter and put it behind the desk.
Included within the group are several clipboard nurses and a few other unidentified surveyors.
The clipboard doc is the best. He’s about 70 years old and is a retired dermatologist. He looks kinda lost. He just walks around listening to people tell him what to do.
Out of all the safety measures in the hospital that they had to survey, we got dinged because one of the charts had an “unapproved abbreviation” and because there was a lidocaine bottle that wasn’t locked up after we got done sewing up a laceration. But Clipboard Doc, not to be outdone, dinged us because … we had holiday stickers up on the windows of the trauma rooms.
[Gasp!]
After all, those holiday stickers “have static electricity and could cause a fire.” In addition, they’re probably “teeming with bacteria and could be a source of infection.” These are the only words that came out of Clipboard Doc’s mouth. Forget the fact that the only thing near the “static electricity” in the holiday stickers is glass and an aluminum door frame. Now the heat generated in a static electricity spark is probably less than the melting point of glass (about 573 degrees Celsius) and the melting point of an aluminum door frame (about 660 degrees Celsius), but maybe someone will walk by the door, pass gas, and the gas will loft up, cause the holiday sticker to curl up and pull away from the door, releasing a spark of static electricity that ignites the methane gas and causes an explosion.
Hey – it could happen.
The infectious disease point is well-taken, too. I can’t think of how many times I’ve walked into a room and just had the urge to rub my hands all over the holiday stickers on the windows before touching a patient’s open wounds.
Then I thought of another point: The doors to the trauma bays are made of glass. Nearsighted retired septagenarian physicians might not see the glass and might walk into the doors, banging their heads and causing a subdural hematoma. Worse yet, the impact from the head bang could cause the doors to shatter and a piece of glass could fall off the frame, lodge between a patient’s ribs, and cause a sucking chest wound.
Damn. Not only did we have to get rid of the holiday stickers, now we’re going to need to replace these doors with plexiglass.
This little charade makes me wonder if these surveyors cite hospitals for silly random “violations” as a joke – just to see everyone run around and fix them. Doubt it, but I have to admit that it would be kind of funny if that really were the case.
By the way, someone sent me a picture of the JCAHO “Mother Ship” and figured that I would post it so everyone sees how little money is earned by creating reams of safety standards every year.
Look ma – no holiday stickers in the windows, either.
Posted in Health, Joint Commission | 29 Comments »
Thursday, August 14th, 2008
 I have to stop reading Kevin’s blog.
Lately, every time I read through his posts, I get all riled up over something. The most recent thing to get my blood boiling was Kevin’s link to a nice rant on Buckeye Surgeon’s blog about these looming Medicare “Never Events.” There’s a journalist in Cleveland named Diane Suchetka who published a “blind leading the blind” article about “never events” in the Health News section of Cleveland.com.
I know that I’ve beaten this whole “never event” horse before, but the whole concept is just so remarkably brain dead that I had to get my whip out again.
The thing that concerns me the most about the “never event” concept right now is that many members of the general public are jumping on this bandwagon. Like foie gras ducks being force-fed corn, the citizens of this country are being force fed the notion of “never events” by the government and insurance agencies. Even more disconcerting is that the feeble minded among us actually believe that all of these “never events” should never happen. Just look at the comments to Ms. Suchetka’s article.
After reading the article and the comments, I added my own comment:
It is unfortunate that someone so misinformed about the effects of “never events” on the practice and accessibility to medical care is allowed to publish an article like this. It is even more unfortunate that so many of the members of the general public support Ms. Suchetka’s ramblings.
First of all, look at the contradictions contained within this article itself. She quotes someone from “SHIC” as saying that “If hospitals were to set up efforts to follow these longstanding practices, the vast majority of these medical errors and infections could be prevented.” Wait a second. “Vast majority?” I thought that these were “never events.” Shouldn’t Captain Obvious have stated that the events would “never” happen if the policies were followed?
Medicare calls the “errors” “reasonably preventable.” If they are “never events,” shouldn’t they be called “entirely preventable”? If they are “never events” then I want to see the people who came up with that term treat patients for a year and show me their results in preventing them.
There are other misstatements. Realitynurse states that “C. diff is a medical mistake.” Uninformed and untrue statement. C. diff is an organism that lives and grows just like every other organism on this planet. Antibiotic use may increase the prevalence of C. diff, but antibiotic use does not “cause” C. diff. Your statement is akin to saying “mosquitoes are a mistake” or “uninformed nurses are a mistake.”
Why has C. difficile become so ominous? Up to 20% of people prescribed clindamycin can develop C. difficile. What exactly should we do to make sure that not one single patient ever develops a C. difficile infection? Go on. I want all you smart people to tell me. Stop prescribing all antibiotics? Sounds like a plan. Then Medicare will deem all the other infections as “never events,” too.
If any of the people reading this column want to avoid never events, here’s how to do it: Don’t go to doctors and stay away from hospitals. That’s right. Boycott us. If you want to create a manual on how to provide perfect medical care while you’re treating yourself for a ruptured appendix, I’d be happy to read it.
Ms. Suchetka is right that these Medicare rules will affect all of us, but she has the wrong reasoning. They will affect all of you that develop these conditions because physicians and hospitals will avoid you like the plague. If you are prone to falling, good luck finding a doctor to treat you. Immunocompromised and likely to develop infections? Better read up on those medical journals. You’ll be treating yourself soon.
“Medicaid expenses could drop”? Get a clue. They won’t drop, they’ll increase. No one will accept Medicaid patients with predispositions to these conditions and the patients will end up in the emergency department where the care is really inexpensive. Maybe Medicaid should focus its efforts on reigning in those that misuse their access to health care in order to score some pain meds. That would save a lot more money than this all this hogwash about those things that are and are not preventable.
Hospitals are “get[ting] the message” alright. They’re closing. Doctors are getting the message, too. Fewer and fewer specialists are treating patients from emergency departments because they don’t want to deal with people who expect perfection and who then try to sue when they don’t get it.
When your local hospital closes down or when the wait for care is so long that you or a loved one develop a bad outcome because of it, you can thank people like Ms. Suchetka for putting pablum to paper.
Boy am I glad I’m a doctor.
WhiteCoat
The comments on the blog have to be approved by the blog owner and at this point Ms. Suchetka or whoever “owns” the blog has still not “approved” my comment about her uninformed article.
I just decided that I’m not finished yet. Now you’re getting both barrels, lady.
A DVT will soon be a never event. Indirectly what CMS is saying is that blood should never clot. If blood should never clot, then why doesn’t CMS make Coumadin ingestion mandatory for every person in the United States? We’ll just put rat poison in the water supply and force everyone to go for their monthly INR checks. Oh, wait – maybe it’s only that blood should “never” clot in the legs. Where do I get my own set of government-issued Ted Hose? And another thing – all you airlines better give me upgrades to first class or I’m not paying for my flights. What’s fair for medicine is fair for the travel industry. “Never” means never.
C. difficile and Staph aureus infections are also going to be considered “never events.” Think about the idiocy of this classification. Mircoorganisms should “never” happen. You sonofabitches in the government give us a vaccine to eradicate smallpox but you’re holding out on the C. diff vaccines so you can avoid paying for medical care, aren’t you? How long before strep throat, otitis media, pneumonia, H. pylori gastritis, and urinary tract infections will also be never events? Ooops. UTIs already are never events. Don’t forget about tooth decay, either. Stinking peptostreptococcus bugs. Oh yeah – yeast infections, too. Monistat will soon be mandatory for all women. The human body should be absolutely sterile.
“Never events” are and always have been “all about the Benjamins.” Look at this news release. The “background” section states that the “never events” were “required” pursuant to Section 5001(c) of the Deficit Reduction Act. Medicare wants to stop paying for things not because they “should never happen” but because it’s trying to save money. The whole “never event” moniker is just a spin they put on the cuts to make it look like someone else’s fault. Do “never events” never occur at government run hospitals? We’ll never know because CMS doesn’t even include government run hospitals on the “hospital compare” list.
Am I the only one that finds it odd that CMS is so willing to judge others but is so unwilling to allow others to judge it?
Just like the guy that cuts your lawn, your attorney, or any other entity that performs services for you – once you stop paying for the services, you stop getting the services. Medical care will be no different. Economic forces will make it more and more difficult to find care if you are predisposed to a “never event.”
In addition, medical providers will find loopholes in the “never event” system that will drive up the costs of care instead of decreasing it. Maybe your doctor will transfer you to another hospital for “specialist care” after you develop a “never event” so that the new hospital can bill for it. Maybe you’ll suddenly develop some other medical condition that the hospital can bill for while you are treated for the uncompensated “never event.” Trust me – medical providers are a helluva lot more creative than the people working at the Medicare National Bank.
Rest assured that whatever happens, the laws of unintended consequences will increase the costs of treating “never events” and Medicare’s inevitable decline into bankruptcy will occur even more quickly because of it.
Other countries must just be watching us, smirking, and shaking their heads.
Get your healthcare while you can. If you still believe that never events should never occur, you better get your treatment for delirium quickly – delirium is one of the conditions on the “never event” hit list.
P.S. I’m still glad that I’m a doctor.
Posted in CMS, Health, Insurance, Joint Commission, News Commentary | 10 Comments »
Saturday, February 23rd, 2008
A post at GirlVet’s blog made me crack up about the pain scale that the Medical Marijuana Advocates make us document on all our patients. I know that the pain scale is one of Nurse K’s pet peeves, too.
When we describe the pain scale, we try to give example to illustrate what a “10″ on a 1-10 scale is. Some people just don’t seem to know what 10 out of 10 pain really means. How do we get the point across?
I have heard the following descriptions:
“The most unimaginable, indescribable pain you could ever have in your life.”
“Someone lit your body on fire and put it out with a track shoe.”
“Someone ripped both your arms and legs off.”
“You got run over with a steamroller.”
The one I use is that 10 out of 10 pain is pain that is bad enough that you are “on the ground wailing and pounding your fists on the floor because the pain is so bad.” This gives me an objective way to follow up the subjective ratings of “10.”
“So using my description, how bad is your pain from 1-10?”
The patient, sitting on the bed munching Doritos and watching TV, says “Oh, it’s definitely a 10.”
I reply, “That’s funny, because you’re still sitting on the bed, you’re not pounding your fists on the floor, and you’re not wailing. In fact, you appear to be rather comfortable.”
The usual response?
“Oh, then it’s a nine and a half.”
Yeah, right. Even Paris Hilton can act better than that.
So how does everyone else describe 10 out of 10 pain? I’d like some fresh ideas.
UPDATE FEBRUARY 27, 2008
First, thanks to everyone who responded to this post. All of your experiences have helped me (and hopefully others) put things into a little better perspective.
One of the things I have noted is how variable people’s perception of 10 out of 10 pain really is. Kind of like having a bunch of different rulers. On one ruler an inch equals 2 centimeters, on another an inch equals 5 centimeters, and on a third an inch equals 16 centimeters. How can we have an accurate measurement of pain if we don’t have a standard way to measure it? We can use “gall bladder attack” or “kidney stone” as baselines, but people who have never had those problems would have nothing to compare their pain to. Similarly, guys have no idea what “labor pain” feels like. Right now everyone is walking around with different “rulers.”
Second, it is interesting to me how many people commented on how useless this “fifth vital sign” really is. People in true pain under-report their pain and those with the “worst pain in their lives” go about their daily activities as if nothing is wrong while waiting for their magical pain shot.
All that this extra administrative burden of “pain scale” reporting has done is to make health care personnel look at patients complaining of severe pain with a questioning eye and to make patients afraid of accurately rating their pain because they are afraid of being labeled as drug seekers.
So these “standards” that health care personnel are required to use aren’t really “standards” at all. In practice, they seem to be harming patient care more than they help.
Isn’t there something fundamentally wrong with this picture?
Are you listening, Joint Commission?
Posted in Health, Joint Commission, Random Thoughts | 84 Comments »
Tuesday, February 5th, 2008
In law there is a doctrine called strict liability.
Strict liability means that no matter what you do to protect someone from an injury, if the person suffers an injury, you are liable for the consequences. You could have taken every possible precaution. Doesn’t matter. Injury = liability.
Usually strict liability is reserved for inherently dangerous activities, such as raising pet alligators or demolition. You want to blow things up? You better make darn sure that no one could possibly get hurt. Strict liability also applies to manufacturers who create products for human use. If someone gets harmed using the products, the manufacturer is liable for the injuries. Otherwise, manufacturers would feel comfortable putting potentially dangerous products on the market.
Now some insurance companies and our own federal government want to impose strict liability on hospitals. I started thinking about this the other day when we had a rash of patients who came in with injuries after slipping and falling. According to Medicare and to a growing number of insurers, falls are one of the growing list of “never events” that are not worthy of reimbursement. For example, see this January 7 article in American Medical News.
Here are a few more articles about insurers refusing to pay for the never events:
WSJ Article — Insurers Stop Paying for Care Linked to Errors
AM News — No Pay for “Never Event” Errors Becoming Standard
Group Calls on Hospitals to Waive Payments for “Never Events”
Don’t miss Happy Hospitalist’s “fairy dust” post about “never events,” either.
The National Quality Forum has identified 28 medical errors as “never events.” In other words, these 28 events should “never” happen. Some of them I agree with. For example, leaving an object in a patient after surgery should probably never happen. Operating on the wrong body part or performing the wrong surgery on the wrong patient should probably never happen.
But the list starts to get a little hazy the more you read it.
According to the NQF, patients should never die or have a “serious disability” associated with the use of contaminated drugs, devices, or biologics. First, notice how the hospitals are being put on the hook for products that the manufacturers provide to them. According to the NQF, if hospitals use a product in good faith and there is a “bad outcome” because of contamination of that product, the hospital doesn’t get paid. No matter what. Flu vaccine wasn’t packaged appropriately and someone gets sick from it? Doesn’t matter, hospital, you’re not getting paid to take care of the consequences. You are completely liable for the damages.
Applying this concept to the everyday world would mean that … contamination should never happen. If my kid pukes from spoiled milk in the refrigerator, the milk manufacturer should have to pay for all the medical treatment necessary to make my kid feel better.
According to the NQF, patients should never die or have a serious disability if a device is “misused” or “malfunctions.” If a poorly designed (but FDA approved) device is used in a hospital and the device malfunctions, the manufacturer who made the device bears no responsibility for the patient’s care. It only matters where the injury occurs. Because the device was used in a hospital and the injury occurred in the hospital, the hospital should have to pay for all of the care related to the malfunction. Makes a lot of sense.
Applying this concept to the everyday world would mean that … if the turn signal in my car malfunctions, I get into an accident, and I hurt my back, the city in which I am driving the car should have to reimburse me for my injuries. Doesn’t matter who manufactured the car, it only matters where the injury occurred when I was using the car.
According to the NQF, patients should never attempt suicide resulting in serious disability. Great idea. Impose strict liability on a hospital to ensure that no one has unexpressed suicidal tendencies on the inpatient wards. Maybe we can have a dream analyzer and personal psychotherapists for each patient. Every patient who is admitted should have a 24 hour sitter just to catch that one patient who wakes up from surgery craving a handgun, seeing flashbacks from the movie “Saw,” and saying, “Well, the surgery went OK. Rats. That didn’t work. Maybe I’ll try to hang myself to get out of paying the hospital bill.” Wonder if Glenn Beck’s insurers paid for his inpatient detox because of his suicidal thoughts after his hemorrhoid surgery.
Patients should never have a serious disability associated with a drop in blood sugar. Diabetics know that hypoglycemia “never” happens. Blood sugar drops … patient gets out of bed … patient drops … patient’s head bounces off floor … hospital pays. Strict liability.
The best one is that the NQF asserts that there should be strict liability when a patient suffers death or serious disability associated with a fall in the hospital. Falls should never happen. Everyone always ties their shoelaces. Old people always use their walkers. Dizzy people don’t exist. The unsteadiness and shuffling gait seen in Parkinson’s Disease? A figment of our imagination. If someone falls in the hospital, the hospital is liable.
Well, we can restrain demented patients who are fall risks, right? Wrong. Medicare rules only allow for the “least restrictive method” of restraint and must be discontinued at the “earliest possible time.” Restraint orders are good for a total of 24 hours.
Hospitals could have sitters watch old people who try to climb out of bed. As if the nurses aren’t overworked enough. Hey, now you have to dispense meds, clean patients, chart, feed patients, talk to families, talk to doctors, try to find some time to pee once per shift, be nice, AND watch all of your patients all of the time so they don’t fall out of bed. Why didn’t I think of that sooner?
Suppose a hospital believes that sitters are necessary to comply with these silly rules. Who is going to pay for the sitters? Won’t be the insurers. Won’t be the government, either. Enter the ABN. You have a sick relative who might fall in the hospital? YOU or your family might be stuck paying for these extra services to prevent these “never events” – even if they are unlikely to occur. If you refuse the services, maybe you’re going to be paying for any costs related to falls out of your own pocket. Insurance companies won’t pay for them – they’re “never events.” Hospitals will say that they gave you the opportunity to prevent the fall by paying for a sitter and you refused. Get ready for a jump in the cost of care.
Insurance companies allege that they have “patient safety” in mind when they implement these rules. Perhaps that is true. Are the costs associated with achieving 100% patient safety worth it when there are so many people in this country who can’t get basic health and dental care?
I think there’s another reason for these “safety rules.” With all the money that insurance companies save by by refusing to pay for these “never events,” does anyone actually think that the premiums for health care insurance are going to go down?
Charge more for premiums, pay less for medical care. Insurance companies have it made.
Soon even those with insurance could be in danger of bankruptcy due to hospital charges.
But that would “never” happen, would it?
Posted in Health, Joint Commission, Medical-Legal, News Commentary | 18 Comments »
Friday, January 25th, 2008
Below is an entry in a chart from a patient that was sent to me.
From what I could read of the whole chart, it seems like the doctor who wrote this provides good medical care.
The issue is this: If the Medical Marijuana Advocates think that medicine is suddenly going to be saved from itself by forcing the entire medical industry to use some arcane set of rules when they write medications or medical orders, they’re wrong.
Stop putting the emPHAsis on the wrong sylLAble.
People are murdered with knives every day. We don’t make all the knives dull, we prosecute the people who misuse them.
Bad drivers kill and maim hundreds of people every day. We don’t force car manufacturers to put 2 foot cushions around the perimeter of the cars, we focus our attention on those people who drive poorly.
When lawyers file frivolous lawsuits we don’t …. nevermind, bad example.
Focus on the problem.
Don’t write “Q” before “D.” Don’t use “u” so it isn’t confused with “cc” – and by the way, you shouldn’t be using “cc” anyway, only “ml” … which shouldn’t be confused with microliter – ul. Don’t use “<” because some four year old might get it confused with “>” and don’t use “>” anyway because it might look like a “7″ – or even a fancy “T” for that matter. Should we maybe just change the grade school textbooks to get rid of “<” and “>” altogether because some people aren’t smart enough to figure them out?
So let’s say JCAHO’s mandates are an overwhelming success. Everyone in the entire world … do they have a Medical Marijuana Advocates equivalent in Bucharest, I wonder …. anyway … everyone in the world only writes approved letters and makes sure that all decimal points are preceded by a “0.” Are all of these monstrous changes that have cost us millions of dollars to implement really going to improve the medical care provided by physicians with poor handwriting?
If there is an issue with certain physicians who write poorly, here’s a newsflash: Discipline the physician. Penmanship classes. Block letters. Typewritten orders. Make them hire a scribe. Ding ding ding ding ding. Win-win situation, here. Nurses actually understand the orders. Pharmacists can correctly fill prescriptions without flipping a coin. I don’t keep pulling my hair out from inane micromanagement.
Think there’s a lack of primary care physicians now? Do everything you can to make the job more appealing to those who know how to write like an adult. Keep all the useless picayune rules coming. Sit in conference rooms spending hundreds of thousands of dollars to see what hoops you’re going to make everyone jump through next, rub your hands together with an evil giggle, and couch everything in the name of “patient safety.”
While you’re at it, think about this: How safe will the patients be when there is no one left to care for them because you have helped make the practice of medicine so unappealing?
Posted in Health, Joint Commission | 17 Comments »
Sunday, November 4th, 2007
I’m about fed up with the chart police dinging me for writing “unapproved abbreviations.” This whole “Do Not Use List” is another Medical Marijuana Advocates idea that has just gone too far.
- I can’t write “U” anymore because it could be mistaken for any of the following: “0,” “4″ or “cc”
- I can’t write QD or QOD because the period after the Q might be mistaken for an “I” and the “O” might be mistaken for an “I”
- I can’t write “MS” for morphine sulfate because someone might confuse it for magnesium sulfate. Similarly, MSO4 and MgSO4 might be confused.
We’re soon going to be blessed with even more additions to the “Do Not Use List”:
- Don’t write “> or <” because they could be mistaken for the number “7″ or the letter “L”
- Don’t write “&” because it could be mistaken for the number “2″
- Don’t write “cc” because it could be mistaken for “U” (units) when poorly written. Instead we will have to write out the term “ml” instead.
There are other “safety measures” to keep us from hurting ourselves, but these are the ones that stick out most in my mind.
Now hold on a second while I get my soapbox.
Tap tap tap. Is this thing on?
There, that’s better.
The “U” for units might get confused with a number “0″
Maybe there could be some confusion.
Now let me ask the nurses a question: If you get an order for “500 reg insulin SQ,” are you going to
(a) question the order or
(b) fill up a 30 cc syringe (HA! I wrote “cc” instead of “ml” – cc cc cc cc cc) with regular insulin and inject a bolus the size of a kiwifruit under someone’s skin?
Would any medically trained person give “50 regular insulin” instead of “5 u regular insulin” to someone with a glucose of 250? I didn’t think so.
So this rule must have been written for people who have no knowledge of how to use insulin – just in case the housekeeping staff wants to get into the act and start treating hyperglycemia on the sly.
While I’m at it, will all of the communications from Medical Marijuana Advocates be required to go without the “cc” designation, too? What a waste of trees. Have to write a new letter to every addressee.
We can’t use MSO4 and MgSO4 because someone might not know that MSO4 is morphine and MgSO4 is magnesium
Would anyone question why a physician was giving a patient with a kidney stone 10 mg of Magnesium for pain? Considering that the dose of magnesium is usually 1000 mg, would it not set off a red flag in a normal person’s mind when you have to use a micropipette to get the proper dose of a medication and then administer three drops to medicate the patient?
And what better way to terminate an episode of torsades de pointes than 1 gram of morphine IV over 30 minutes? Just think, junkies from miles around would figure out ways to put themselves into cardiac arrhythmias just to get treated in your ED! I can see them now: Hey! Wait a minute, JACK! NOOOObody said nothing about no motherf%#$ing shocks!
The ampersand “&” might be mistaken for a “2″
First, I want to know who even writes ampersands any more. Then I want to see how someone can morph an ampersand into a number 2. Right after that, they can go to my bank and turn the $155 dollars in my checking account into a king’s ransom. Not happening.
“> or <” could be mistaken “7″ or “L” and “cc” could be mistaken for “U” (units) when poorly written
I understand how an order to give “10 cc insulin SQ if BGL 7 350″ would be confusing. I routinely dose insulin by “cc” instead of “units” and I frequently see blood glucose levels more than 7000 in my daily practice (the normal glucose level is between >0 and 110). I thought long and hard about this one, though, and have come to the conclusion that we should probably stop using the “ml” term also. Because if written poorly, “ml” might actually appear to be the number “11111″ which could accidentally increase the dosage of any medication by 11111-fold.
See? Instead, I propose that we use the symbol from the Artist Formerly Known as Prince:
Think of how many times we could avert the tragedy of some poor patient getting a 50011111 bolus of saline.
A period in Q.D or the letter “O” in QOD might be mistaken for an “I”
Good point. But because they are so confusing, we shouldn’t just stop at using “.” and “O” with Q.D. and QOD, we should stop using them altogether. By doing so, we would avoid confusing orders such as “STIP patient’s ciumadin NIW”
And this whole thing just gives me flashbacks about one time when I narrowly escaped ordering emergency dialysis for a patient whose potassium level looked like it was “315″ on the computer printout. Boy was I embarrassed. Oh, and I almost forgot the time I nearly intubated a patient whose pH appeared to be 7144. Phew!
Attention Medical Marijuana Advocates …
Here’s a patient safety measure for you:
If health care providers are so incapable of determining whether a dose of medication is 100 times more than it should be and are at such a loss of medical knowledge that they can’t remember whether to use morphine or magnesium for pain management, they either need to call the physician to clarify the order or they need to find another profession.
Maybe they could work for the Joint Commission. Betcha they’d fit right in.
Update:
Want to see one solution to the medical abbreviation problem? Check out this post on physician handwriting.
Posted in CMS, Health, Joint Commission | 43 Comments »
Tuesday, October 23rd, 2007
JCAHO quietly changed its name. Now it wants to be known as the Joint Commission. Joint Commission. Joint Commission. Joint Commission.
I have to write a letter to my congressman. This name leads to confusion. How are healthcare practitioners supposed to function if they don’t know what the organization stands for?
Does it refer to a joint effort at a charitable mission? Even I know that one’s not true. A bunch of plumbers fixing plumbing joints? Maybe a gaggle of rheumatologists? Or could it be a clandestine group of medical marijuana advocates? Maaaaybe its a bunch of neer-do-wells that are jointly plotting the commission of some heinous acts. Wouldn’t want people like that looking over my shoulder.
We have to force them to change their name. Way too confusing. Might lead to phone call errors. Could be bad outcomes. In fact, there was a study in Kazakhstan clearly demonstrating health care in that country was adversely affected when their national health ministry went by a similar name.
I’m starting a petition.
Now.
The only problem is that I don’t know what the Joint Commission’s name should be changed to. Any suggestions??
UPDATE APRIL 22, 2008
See what I mean?
Posted in Joint Commission, Random Thoughts | 15 Comments »
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More On Medicare Never Events
Thursday, August 14th, 2008Lately, every time I read through his posts, I get all riled up over something. The most recent thing to get my blood boiling was Kevin’s link to a nice rant on Buckeye Surgeon’s blog about these looming Medicare “Never Events.” There’s a journalist in Cleveland named Diane Suchetka who published a “blind leading the blind” article about “never events” in the Health News section of Cleveland.com.
I know that I’ve beaten this whole “never event” horse before, but the whole concept is just so remarkably brain dead that I had to get my whip out again.
The thing that concerns me the most about the “never event” concept right now is that many members of the general public are jumping on this bandwagon. Like foie gras ducks being force-fed corn, the citizens of this country are being force fed the notion of “never events” by the government and insurance agencies. Even more disconcerting is that the feeble minded among us actually believe that all of these “never events” should never happen. Just look at the comments to Ms. Suchetka’s article.
After reading the article and the comments, I added my own comment:
The comments on the blog have to be approved by the blog owner and at this point Ms. Suchetka or whoever “owns” the blog has still not “approved” my comment about her uninformed article.
I just decided that I’m not finished yet. Now you’re getting both barrels, lady.
A DVT will soon be a never event. Indirectly what CMS is saying is that blood should never clot. If blood should never clot, then why doesn’t CMS make Coumadin ingestion mandatory for every person in the United States? We’ll just put rat poison in the water supply and force everyone to go for their monthly INR checks. Oh, wait – maybe it’s only that blood should “never” clot in the legs. Where do I get my own set of government-issued Ted Hose? And another thing – all you airlines better give me upgrades to first class or I’m not paying for my flights. What’s fair for medicine is fair for the travel industry. “Never” means never.
C. difficile and Staph aureus infections are also going to be considered “never events.” Think about the idiocy of this classification. Mircoorganisms should “never” happen. You sonofabitches in the government give us a vaccine to eradicate smallpox but you’re holding out on the C. diff vaccines so you can avoid paying for medical care, aren’t you? How long before strep throat, otitis media, pneumonia, H. pylori gastritis, and urinary tract infections will also be never events? Ooops. UTIs already are never events. Don’t forget about tooth decay, either. Stinking peptostreptococcus bugs. Oh yeah – yeast infections, too. Monistat will soon be mandatory for all women. The human body should be absolutely sterile.
“Never events” are and always have been “all about the Benjamins.” Look at this news release. The “background” section states that the “never events” were “required” pursuant to Section 5001(c) of the Deficit Reduction Act. Medicare wants to stop paying for things not because they “should never happen” but because it’s trying to save money. The whole “never event” moniker is just a spin they put on the cuts to make it look like someone else’s fault. Do “never events” never occur at government run hospitals? We’ll never know because CMS doesn’t even include government run hospitals on the “hospital compare” list.
Am I the only one that finds it odd that CMS is so willing to judge others but is so unwilling to allow others to judge it?
Just like the guy that cuts your lawn, your attorney, or any other entity that performs services for you – once you stop paying for the services, you stop getting the services. Medical care will be no different. Economic forces will make it more and more difficult to find care if you are predisposed to a “never event.”
In addition, medical providers will find loopholes in the “never event” system that will drive up the costs of care instead of decreasing it. Maybe your doctor will transfer you to another hospital for “specialist care” after you develop a “never event” so that the new hospital can bill for it. Maybe you’ll suddenly develop some other medical condition that the hospital can bill for while you are treated for the uncompensated “never event.” Trust me – medical providers are a helluva lot more creative than the people working at the Medicare National Bank.
Rest assured that whatever happens, the laws of unintended consequences will increase the costs of treating “never events” and Medicare’s inevitable decline into bankruptcy will occur even more quickly because of it.
Other countries must just be watching us, smirking, and shaking their heads.
Get your healthcare while you can. If you still believe that never events should never occur, you better get your treatment for delirium quickly – delirium is one of the conditions on the “never event” hit list.
Picture credit here
P.S. I’m still glad that I’m a doctor.
Posted in CMS, Health, Insurance, Joint Commission, News Commentary | 10 Comments »