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CQ Researcher Alert!
Feb. 9, 2012
“Patient Safety” by Barbara Mantel, Feb. 10, 2012
Are health care providers doing enough to prevent harm?
More than 12 years have passed since a groundbreaking report on preventable patient deaths in hospitals alerted the nation to a crisis in patient safety. Galvanized into action, the federal government poured money into research and training, patients and families formed advocacy groups, private and government insurers began refusing to reimburse medical institutions for the most serious preventable injuries and hospitals developed systems to track patient harm at the insistence of accreditation agencies. Yet patients continue to suffer high levels of death and injury from medical errors, and the health care industry, government regulators, insurers and patient advocates are struggling to figure out how to tackle the problem. Bloodstream infections caused by contaminated catheters are among the most dangerous threats, and hospitals are taking strong steps to prevent them. Meanwhile, medical experts are debating the value of patient involvement in safety procedures.
By Jennifer Weeks
Major areas of the United States, including the Great Lakes and Rocky Mountains, have been invaded by non-native species that are causing widespread economic damage. Many imported plants and animals are harmless in new locations, but some thrive, upsetting natural balances and altering ecosystems. Biological invasions put native species at risk and cause millions of dollars in property damage yearly. Climate change is expanding the range of tropical organisms and making it possible for some native species, such as western bark beetles, to spread at high rates. To stem the tide conservationists want to tighten U.S. import controls so that harmful species can be screened out. But the exotic-pet industry – a major source of invasives – argues that this approach undercuts private rights. Meanwhile, regulators face hard choices about which species to control with limited resources.
By John Felton
Nearly 40 years after U.S. astronauts last walked on the moon, America’s space program faces what could be its most serious challenges ever. With the end of the space shuttle program, the U.S. government can no longer put humans into space. NASA is working on ambitious programs for human and scientific explorations of space, but budget cuts could curtail those aims. Moreover, no consensus has emerged as to what the next destination for humans should be: the moon, a nearby asteroid or Mars. Meanwhile, China is ramping up its spending and could be the next big superpower to dominate space.
By Marcia Clemmitt
Taxpayer-funded perks offered to companies to relocate or retain jobs in specific localities have proliferated over the past decade, with an estimated $45 billion or more handed out annually. States and cities have offered bigger and bigger incentive packages – which often take the form of tax credits or other abatements – to compete with one another for jobs. Economic-development officials and companies that have relocated for subsidies say the incentives have created jobs and helped some businesses stay profitable. But critics, who include many economists, argue that the incentives bring in relatively few jobs and are not worth the cost to state treasuries.
“Emerging Central Asia” by Brian Beary, Jan. 17, 2011
Can democracy take root in the “Stans”?
Since emerging from the Soviet Union’s orbit 20 years ago, the five nations of Central Asia – Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan and Uzbekistan – increasingly are popping up on geo-political radar screens. Given the proximity of the “Stans” to Afghanistan, where NATO continues to wage war on Al Qaeda and the Taliban, Western powers are ardently wooing Central Asia’s leaders in an effort to maintain military bases in the region. There are also rich resources at stake. Kazakhstan and Turkmenistan’s abundant oil and gas reserves have made them magnets for foreign investors, especially from energy-hungry China, as well as from Europe and the United States. Central Asia also faces a daunting array of domestic challenges, from bloody ethnic clashes and Islamist terrorist attacks to criminal gangs that traffic in drugs and human beings. Meanwhile, some experts wonder if Central Asia, with its repressive, dictatorial leaders and weak but deeply corrupted governments, will soon see its own version of an “Arab Spring” – a popular uprising that will sweep away its aging regimes.
Rising Tension Over Iran
Successive U.S. presidents have insisted that a nuclear-armed Iran is “unacceptable.” Iran’s Islamic leadership insists that its nuclear program is for peaceful purposes only, but even as U.N. inspectors headed out to Tehran in late January, the body of evidence from earlier inspections raised nagging questions that the Iranians have failed to answer, such as why facilities for a peaceful program are buried hundreds of feet underground. A nuclear Iran would alter the strategic balance in the tense Middle East and, some say, possibly trigger a regional nuclear arms race. Although the United States and Europe have imposed tough economic sanctions on Iran, it has not stopped its uranium-enrichment activities or operated its nuclear program with more transparency. But with Israel reportedly considering a preemptive strike on nuclear facilities in Iran – which has vowed to destroy Israel – the question of the sanctions’ effectiveness may be moot.
Responding to the demand for in-depth coverage of global affairs from reliable sources, CQ Press has expanded its flagship CQ Researcher product line with the release in April 2007 of CQ Global Researcher.
The world isn’t one-dimensional, and student understanding of world news shouldn’t be either. CQ Global Researcher authoritatively delivers the world as it is: multi-dimensional and nuanced. Like the CQ Researcher, the CQ Global Researcher presents single-topic reports that home in on current crises and events – this time on an international level – in a way that is at once digestible and substantial. Popular sections such as “Current Situation” and “Pro/Con” are joined in the CQ Global Researcher by the new “Voices from Abroad,” which presents a multitude of international viewpoints on vital current issues. Maps, charts, and other explanatory graphics abound as well.
CQ Global Researcher’s powerful online tools – a hallmark of CQ Press online resources – complete the package:
“Hate Groups,” May 8, 2009:
“An extremely well-done investigative piece. Very objective and well-researched; great writing. From one investigator to another, good work!”
– James Cavanagh, special agent, Bureau of Alcohol, Tobacco, Firearms and Explosives
“Auto Industry’s Future,” Feb. 6, 2009
“Covers an enormous amount of ground in a very useful way. By quoting a number of industry experts, will help prepare everyone from staff arranging a congressional hearing to potential investors to the general policy community.”
– Kent H. Hughes, Director of Science, Technology, America and the Global Economy, Woodrow Wilson Center, Washington
“Public Defenders,” April 18, 2008:
“I must tell you that the article is clearly among the very best I have ever read on a topic that I have studied for over 40 years.”
– Robert Spangenberg, President, The Spangenberg Group
“Racial Diversity in Public Schools,” Sept. 14, 2007:
“What a fabulous piece! Well balanced, well thought out and clear to the lay person.”
– Richard D. Kahlenberg, Senior Fellow, The Century Foundation
“Wounded Veterans,” Aug. 31, 2007:
“This is an amazing article. I especially like the chart dealing with the ratio of wounded/fatalities, I knew the numbers but the graph helps bring home the point.”
– Patrick Campbell, Legislative Director, Iraq & Afghanistan Veterans of America
“China in Africa,” January 2008:
“A shining example of what a truly brilliant research resource can be.”
– Library Journal
“I am really amazed by the strength and quality of your work. One of the most impressive publications on the subject of China in Africa. I am sure this will be a landmark contribution.”
– Adama Gaye, Visiting Fellow, Johns Hopkins University, School of Advanced and International Studies
“Future of Turkey,” December 2007:
“The best and most comprehensive coverage of Turkey in the Western press.”
– Ali Aslan, Washington correspondent for the Turkish daily Zaman.
The comprehensive CQ Researcher index is updated monthly and is available online in PDF format for easy downloading and searching. This up-to-date service replaces the print index sent on a quarterly basis to full-service CQ Researcher subscribers.
Researchers and librarians will find this timely index a valuable resource for finding the most recent CQ Researcher report they’re looking for and, if needed, the index can be printed out each month and included where CQ Researcher reports are stored. In addition, the electronic index is searchable and can be accessed remotely from any location, making it easy to link the index to online catalogs or web pages.
The comprehensive CQ Researcher index is available online at www.cqpress.com/cqr/index.
Issues covered in past CQ Researcher and CQ Global Researcher reports that are in the news now:
A federal appeals court ruled Feb. 7 that California’s voter-approved ban on same-sex marriage is unconstitutional. Supporters of the ban – known as Proposition 8 – said they are willing to take the issue all the way to the U.S. Supreme Court.
Gay Marriage Showdowns, 20080926 (Sept. 26, 2008), updated Oct. 15, 2010
The trial of a University of Virginia lacrosse player accused of murdering his former girlfriend began on Feb. 8. George Huguely V is charged with beating Yeardley Love, also a lacrosse player, to death in May 2010. Prosecutors say he had threatened to kill her after a previous fight.
Crime on Campus, 20110204 (Feb. 4, 2011)
The U.S. Nuclear Regulatory Commission on Feb. 9 approved licenses to build two new nuclear reactors east of Atlanta. The reactors, the first to be approved in the United States in more than 30 years, have raised safety concerns following Japan’s 2011 Fukushima disaster.
Nuclear Power, 20110610 (June 10, 2011)
It was orthopedist David Ring’s last surgery of the day at Massachusetts General Hospital, a straightforward procedure to treat carpal tunnel syndrome on the left wrist of a 65-year-old woman, using local anesthesia.
Everything seemed to go smoothly, but back in his office 15 minutes after the operation, Ring realized he had performed the wrong procedure. The woman was actually scheduled for surgery on a painful, stiff finger.
Ring immediately notified the operating staff – and then hospital administrators – and asked the patient if she wanted him to perform the correct surgery. She did, and he completed the operation without complication.
“Just imagine the worst thing that’s ever happened to you and that’s how it feels,” said Ring of the back-to-back surgeries in 2008. “I don’t want anybody to make the same mistake I made.”
So Ring took an unusual step. He and two colleagues from Mass General wrote in The New England Journal of Medicine about the string of errors that led up to that day’s wrong surgery.
Ring had become distracted by an emotional encounter with an earlier patient; a nurse marked the patient’s hand at the wrist, not at the surgical site; the patient was moved to a new operating room with new staff because other surgeons were behind schedule; and just before operating, Ring spoke to the non-English-speaking patient in Spanish, leading the staff to mistakenly conclude he was conducting a “time-out,” a standard procedure to verify one last time the patient’s identity, surgical site and procedure. But no verification had occurred.
Other medical mistakes – tens of thousands each year – have far more serious consequences, including injury and death due to post-surgical infections, overmedication, contaminated catheters, in-hospital falls and oversight by overworked staff.
In 2002, journalist Michael Hurewitz died at Mt. Sinai Medical Center in New York City after donating part of his liver to his brother. He choked on his own blood three days after the operation. A state probe found that the transplant unit in which Hurewitz died lacked adequate staff, staff experience and supervision. The ward had 34 postoperative patients under the care of a single first-year resident. Following the episode the State Health Department in New York called for beefed-up staffing in transplant units and frequent checks of patients by experienced doctors, among other rules.
Just over 12 years ago, the Institute of Medicine, an independent organization that provides advice to the federal government and public, released a game-changing report, “To Err is Human: Building a Safer Health Care System,” capturing the public’s attention with blunt language and grim statistics: Between 44,000 and 98,000 Americans die in hospitals each year because of medical mistakes. “These stunningly high rates of medical errors ... are simply unacceptable,” said William Richardson, chair of the committee that wrote the report.
The committee’s solution was revolutionary: It was time to stop blaming individual health care practitioners and to start changing the systems that allowed human error to result in patient harm. The report criticized hospital wards stocked with full-strength drugs that are toxic unless diluted; a lack of communication between specialists treating the same patient; and hand-written prescriptions that nurses and pharmacists cannot read. All were systems and procedures that could be changed, the committee said.
But despite federal, state, and private efforts since then, many experts say health care remains unsafe. “If we only improve care as much in the next decade as we have in the last, we are failing the American public,” Kathleen Sebelius, secretary of the U.S. Department of Health and Human Services (HHS), said last October.
While doctors, hospitals, patient advocates and researchers are trying to solve what seems to be an intractable problem, however, they disagree on some important fundamentals: whether, for example, hospital reporting of patient injuries and near misses eats up valuable time or improves patient safety; whether states should require public reporting of serious patient injuries; and whether financial penalties against hospitals are the best way to improve care.
There are bright spots. The Centers for Disease Control and Prevention (CDC) has reported progress in reducing some hospital-acquired infections in 2010, such as those associated with urinary catheters and central lines. Still, the CDC estimates that one in 20 patients – or 1.7 million a year – will get an infection in the hospital.
The real number, patient advocates say, is probably much higher. In fact it is difficult to know the full extent of patient injuries because many are never reported or recognized.
In 2010, the Office of the Inspector General (IG) at HHS released a study that found nearly one in seven Medicare patients suffered serious harm in the hospital in a one-month period, and almost half of those events were preventable. The researchers had reviewed a random sample of patient charts nationwide. A year later, in a follow-up analysis, the IG determined that hospital staff had not reported 86 percent of those incidents to their superiors, partly because they were confused about what constitutes harm. All hospitals that receive Medicare reimbursement must “track medical errors and adverse patient events, analyze their causes, and implement preventive actions,” the IG noted.
A more recent study used a streamlined form of chart review called the Global Trigger Tool. It allows reviewers to look for any of 52 triggers, such as use of an antidote medication, that would indicate something had gone wrong and would prompt a closer look at the chart. In a study of three hospitals, researchers reported that reviewers found serious adverse events in one-third of hospital admissions, at least 10 times more than staff reports.
“We need this kind of data going forward if we are going to understand what’s out there, what is working and where we need to make improvements,” says pediatrician Christopher Landrigan, director of Harvard Medical School’s Sleep and Patient Safety Program at Brigham and Women’s Hospital in Boston. Landrigan would like to see every hospital use the trigger tool. Even just using it on a small sample of patient charts in every hospital would yield “far better information than we have today about how often harm is taking place and what to do about it,” says Landrigan.
The private nonprofit National Quality Forum (NQF) in Washington, D.C., lists 34 “safe practices,” such as procedures known to reduce hospital-acquired infections, checklists to reduce surgical errors and practices to reduce serious pressure ulcers, commonly known as bedsores. But neither the NQF nor the federal government consistently tracks which hospitals are implementing them.
Moreover, “it has become apparent that it is difficult to make these changes because it really requires teamwork,” says physician Lucian Leape, a member of the Institute of Medicine committee that released “To Err Is Human” and a professor at the Harvard School of Public Health in Boston. “But physicians aren’t trained in teamwork. What we are looking for is a very big culture change in medicine.”
The traditional hierarchy of hospitals, where everyone defers to the doctor, has been a major impediment to patient safety, Leape says. The increasing complexity of medical care makes it imperative that doctors consult with other physicians, nurses and health care providers, he says.
In addition, many physicians don’t treat co-workers with respect, Leape says. “Once you have humiliated a nurse, you can be sure she’s not going to call a doctor about a problem if she knows she’s going to get chewed out.”
In fact, in a government survey of patient safety culture in just over a thousand hospitals, fewer than half of staff said they felt free to question the decisions or actions of those with more authority.
Leape says several hospitals have successfully created a patient-safety culture, including the Mayo Clinic in Rochester, Minn.; Ascension Health, the nation’s largest nonprofit health system, with hospitals in 20 states and Washington, D.C.; and Virginia Mason Medical Center in Seattle.
Ever since an accidental injection of antiseptic rather than dye during a brain aneurysm procedure caused the death of patient Mary McClinton in 2004, Virginia Mason has been trying to transform itself into a defect-free health care system. It has adopted many of the NQF’s safe practices, and it has instituted a Patient Safety Alert System, based on a Toyota program that allows assembly line workers who spot problems to “stop the line.”
“Whether they are a housekeeper or a neurosurgeon, they can and should report concerns,” says Cathie Furman, senior vice president for quality and compliance at the medical center. When Virginia Mason began the program, it had three patient safety alerts a month; in December it had 559. “They can be anything from an expired tuna fish sandwich to ‘I almost operated on the wrong person’ and everything in between,” Furman says. The hospital’s goal is to reach 1,000 alerts a month, she says. “That’s how we learn about all the system issues that allow a doctor or person to make a mistake.”
So far, the program has shown good results, Furman says. Infection rates are down, the number of patient falls is down and the hospital’s professional liability insurance premiums have shrunk by double digits every year, she says.
But persuading staff to participate in the alert system hasn’t always been easy, Furman says. The key, she says has been a commitment from the medical center’s top executives.
Massachusetts General Hospital also learned from Dr. Ring’s mistaken operation on his patient’s wrist. Surgeons rather than nurses now mark the surgical site; the surgical scrub nurse is not allowed to hand the knife to the surgeon until the time-out check is finished; all staff are encouraged to speak up with any concerns; and an auditor monitors the entire process.
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