Although it’s relatively rare, mix-ups of patients’ X-rays can lead to dire consequences.

One way to get around the problem of such “wrong patient” errors is to take a photo of the patient’s face at the same time the X-ray is shot, a new study suggests.

If a doctor is looking at the wrong X-ray, the fallout could be catastrophic, said Dr. Srini Tridandapani, the author of the study presented at the annual meeting of the American Roentgen Ray Society.

“The patient could be diagnosed with cancer and then get an operation he shouldn’t have while the patient who should have gotten the cancer diagnosis isn’t getting the surgery. So you could be affecting two patients,” said Tridandapani, an assistant professor of radiology and imaging sciences at Emory University.

No one knows exactly how many times patients are matched with the wrong X-ray each year, said Tridandapani, who conducted the study jointly with the Georgia Institute of Technology. But it’s estimated that these kinds of identification errors occur in 1 out of every 10,000 patients.

While that may seem like a small number, companies like Motorola aim to have no more than one chip in a million fail, Tridandapani noted.

“I think human beings are more precious than chips, so I don’t accept a rate of 1 in 10,000,” he added. “I think we need to get beyond 1 in a million.”

Tridandapani came up with the idea of adding patient photos to X-rays after he answered a call and the image of the caller appeared on his phone.

“It occurred to me that we should be adding a photograph to every medical imaging study,” he said. 

Errors could be reduced simply by adding photos to patient X-rays, he thought.  To test his theory, Tridandapani rounded up 200 pairs of X-rays (one pair per patient) that he gave to 10 radiologists to read.

Each radiologist got 20 pairs of X-rays. Each set of X-rays contained a few pairs that were actually from different patients. The first time he ran his experiment, the radiologists got only the X-rays. The second time, the X-rays came with photos of the patients.

When there was no photo, the group of radiologists caught only three out of 24 mismatches – about 13 percent.  When photos were included with the X-rays, they caught 16 out of 25 errors – or 64 percent.

Part of the problem is that doctors don’t expect to get the wrong X-ray and they often don’t recognize the mistake when it happens, Tridandapani said. They might try to explain away disparities instead of recognizing the errors.

Dr. Albert Wu, who has studied near-misses in medicine, said the new method might, indeed, avoid some dangerous mix-ups.

“This study, on its face makes a lot of sense to me,” said Wu, a professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health and an attending physician at the Johns Hopkins Hospital. 

“If you have the wrong films for someone about to have a procedure you could have a terrible result,” Wu said.

Still, Wu said, there are possible downsides.  When you add photos, radiologists might take longer to read X-rays. And there’s also a question of privacy -- people might not want photos of themselves included in their medical files. Overall, he said, the added safety probably outweighs these concerns.

“I think it’s a pretty neat way to improve patient safety,” said Dr. Ashish Jha, a professor of health policy at the Harvard School of Public Health. “I see very little downside to it, other than the possibility that a physician might read the X-rays differently if it was a man or a woman  -- and I think in general that’s unlikely.”

Even though Dr. Mitchell Schnall believes that the new method makes sense, he’s not sure that his colleagues will jump at the chance to implement it. 

“There’s a lot of pressure on radiology in terms of efficiency,” said Schnall, a professor and chair of the department of radiology at the University of Pennsylvania. “Anything that adds to the workload gets looked at with some skepticism.”

Schnall said radiologists will worry that the addition of photos will mean that each case will take longer to analyze.  But, he added, the photos might actually speed things up.

“For example,” Schnall said, “when you’ve got a patient in the ICU setting there are many tubes and wires in the patient, an external photo would help us know whether those are internal or external.”

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• Why patients don't report medical errors
• Cancer doctor reveals the very dark side of medical mistakes

 

 

Missed or wrong diagnoses in primary care may put thousands of patients at risk of complications each year, a new study suggests.

Although mistakes during surgery and in medication prescribing have been at the center of patient safety efforts, researchers said less attention has been paid to missed diagnoses in the doctor's office.

Those errors may lead to more patient injuries and deaths than other mistakes, according to Dr. David Newman-Toker from Johns Hopkins University School of Medicine in Baltimore, who co-wrote a commentary on the new study.

"We have every reason to believe that diagnostic errors are a major, major public health problem," Newman-Toker told Reuters Health.

"You're really talking about at least 150,000 people per year, deaths or disabilities that are resulting from this problem."

For the new study, researchers used electronic health records to track 190 diagnostic errors made during primary care visits at one of two healthcare facilities. In each of those cases, the misdiagnosed patient was hospitalized or turned up back at the office or emergency room within two weeks.

The study team found the type of missed diagnosis varied widely. Pneumonia, heart failure, kidney failure and cancer each accounted for between five and seven percent of conditions doctors initially diagnosed as something else.

Most diagnostic errors could have caused moderate or severe harm to the patient, the researchers determined. Of the 190 patients with diagnostic errors, 36 had serious, permanent damage and 27 died, according to findings published Monday in JAMA Internal Medicine.

One of the difficulties in making an accurate diagnosis is certain common symptoms - such as stomach ache or shortness of breath - could be signs of a range of illnesses, both serious and not, researchers said.

"If you look at the types of chief complaints that these things occur with, they're fairly common chief complaints," said Dr. Hardeep Singh, who led the new study at the Houston VA Health Services Research and Development Center of Excellence.

"If somebody would come in with mild shortness of breath and a little bit of cough, people would think you might have bronchitis, you might have phlegm… and lo and behold they would come back two days later with heart failure," he told Reuters Health.

Most of the missed diagnoses were traced back to the office visit and the doctor not getting an accurate patient history, doing a full exam or ordering the correct tests, Singh's team found.

Cutting down on those errors may require changes in doctor training, for example. One thing patients can do, the researchers agreed, is come to the office prepared to give their doctor all of the relevant information about the nature and timing of their symptoms.

"I do think it's important for a patient to question or observe the doctor," Newman-Toker said. "Ask pointed questions: ‘What else could this be? What things are you most concerned about?'"

In addition, he told Reuters Health, patients should "not just assume that once the diagnosis has happened the first time, that everything is said and done and that it's all over. You just can't have blind obedience to the doctor's diagnosis."

For example, Newman-Toker said, if people develop new symptoms or their symptoms worsen, they shouldn't assume everything is fine because their doctor initially diagnosed something not serious.

Patients should understand there is some uncertainly involved in a diagnosis, Singh said, especially because symptoms and conditions can change over time.

"We need to get patients more engaged in the conversation with the providers," he said. "I think the main message is: how do we effectively (make diagnoses) together?" 

When Dr. Marty Makary was a medical student, staffers at the Boston hospital where he was training had a nickname for one of its most popular surgeons: Dr. Hodad.

"Hodad" is an acronym for "hands of death and destruction": Despite his Ivy League credentials and board certification, the surgeon had an unfortunate tendency to botch operations so badly that patients often suffered life-threatening complications.

But he was also one of the surgeons most requested by patients, including celebrities, thanks to his charming bedside manner and their lack of understanding about what caused their post-op problems.

Makary, 42, aims to end the professional code of silence that allows colleagues like Dr. Hodad to thrive. Now a cancer surgeon at Johns Hopkins Hospital in Baltimore, Makary has just published the book "Unaccountable: What Hospitals Won't Tell You and How Transparency Can Revolutionize Health Care."

Why patients don't report medical errors

It outlines the extent to which doctors and hospitals suppress objective data about how patients fare in their hands and argues for clear, publicly accessible statistics to help people make the best choices when it comes to treatment. Hospitals and physicians, he argues, should collect "outcomes data" on everything from how many knee-replacement patients walk without a limp to how many prostatectomy patients become incontinent.

Without that, "patients are walking in blind" every time they choose a hospital, Makary said in an interview. With rare exception they have no way of knowing whether they will receive appropriate care or be one of the 100,000 patients killed or 9 million harmed every year in the United States because of medical mistakes.

"There is terrible guilt about keeping quiet, but there are strong social forces against speaking up when you think something doesn't look right: It can get you fired," said Makary. (HealthGrades, a Denver company that develops and markets quality and safety ratings of healthcare providers, rates Makary a "recognized doctor" based on his training and record of no disciplinary actions or malpractice claims.) "You realize as a young doctor that you've walked into an industry with a very dark side."

Clear as mud
In no U.S. state can patients find out what a surgeon's rate of complications is, how many mistakes a hospital makes, how many avoidable deaths it has or almost anything else about a provider's record of care.

Most ratings, from magazines to websites, reflect softer metrics. In the closely watched hospital rankings issued by U.S. News & World report, "reputation," or what specialists think of a hospital, counts 32.5 percent toward overall scores. Patient volume, number of nurses, use of advanced technologies and 30-day mortality rates also count.

The federal government collects and makes public some measures, such as hospitals' rates of complications and mortality after certain procedures, on the Hospital Compare website. About half the states require hospitals to make public what percentage of patients develop infections. While that's better than nothing, says Dr. John Santa of Consumers Union, publisher of Consumer Reports, providers have largely succeeded in hiding their records.

"Despite the best efforts, if hospitals don't have to report something they don't," said Santa.

For example, a regular survey by Johns Hopkins asks staffers at 60 hospitals about safety and teamwork. Studies show that hospitals scoring high on the surveys have fewer surgical complications and better patient outcomes. But hospitals participate "under the condition that the results remain top secret," said Makary.

Specialist groups also gather data, including the Society of Thoracic Surgeons, which tracks national heart-surgery outcomes. Only one-third of hospitals have agreed to post their results on the society's website.

Santa believes patients should have far more data on outcomes, such as what fraction of hip-replacement patients develop infections and what fraction of heart-bypass patients survive, not just currently available information on whether providers follow medical guidelines.

The reason? Good practices may not be a reliable proxy for good safety. A hospital's rate of providing antibiotics after surgery, for instance, does not always correlate with patients' infection rate, said Santa.

The Joint Commission, an independent non-profit that certifies and accredits hospitals and other providers, last week released its annual report summarizing how well 3,300 hospitals did on measures of quality and safety.

Patients can see that a particular hospital was a "top performer" in pneumonia care, meeting criteria such as taking blood cultures in the intensive care unit. But unless a hospital was specifically cited for exceptional care, patients have no way of knowing how good or bad relative to others it is.

More outcomes measures - whether that knee replacement patient walks again, or even dies on the operating table - will be made public in coming years, said Nancy Foster, vice president for quality and patient safety policy at the American Hospital Association. Patients typically choose a hospital based on what their doctor or friends recommend, she notes, adding, "I think there is a lot of opportunity to enrich that process with hard data. The measures currently available are not as consumer-friendly as most of us would like."

The exceptions
Makary notes several models of transparency that have shown promise. New York, Oregon and California require hospitals to report death rates from heart bypass surgery, adjusted for how sick patients were and other factors to make the comparisons fair.

Transparency has benefited patients. After New York made its data public in 1989, hospitals scrambled to improve, and death rates from heart surgery fell 41 percent in four years.

Vitals.com, a doctor-reviews site launched in 2008, recently began incorporating outcomes for cancer and orthopedic surgery from a number of large hospitals into its ratings, said chief executive and co-founder Mitch Rothschild.

"Individual facilities recognize that if they don't weed out bad practitioners, they'll get creamed as Medicare starts penalizing hospitals for poor performance, so they collect these metrics and share them with us," he said.

For other outcome data that hospitals chose not to share, Vitals filed a Freedom of Information Act request to access the government's Medicare health program for the elderly.

"After a year and a half, as legal fees mounted, we gave up," Rothschild said. The government maintains the data cannot be made public for reasons of privacy and others.

In the meantime, the pitfalls for patients are many. When Makary looked Dr. Hodad up years later, he was still thriving and had a five-star rating on a popular review website.

Makary regrets keeping quiet during a residency at a university-affiliated community hospital that boasted of its "comprehensive breast cancer center" and "No. 1 ranking."

Both statements were inventions of the hospital's marketing department, which can make all sorts of claims as long as they are vague enough not to fall afoul of truth-in-advertising laws. The assertion that patients "may" or "often" do better at a particular hospital is allowed, for instance, as are subjective terms like "comprehensive."

Based on such claims, a young patient Makary calls "Gretchen" who needed breast-cancer surgery believed she would get superb care.

In reality, the small hospital did only a few dozen such surgeries per year compared with hundreds at major hospitals. It did not have the expertise to do breast-conserving and -reconstruction surgery, nor were its surgeons adept at the latest procedures.

Makary said he was bothered at the time by the hospital's disingenuous claims and worried for Gretchen, though he did not warn her. He did ask if she'd considered other hospitals, but even that placed him "on thin ice with my own job."

The operation was horribly botched, leaving Gretchen deformed. Not knowing any other outcome was possible, Makary said, she considered herself "very blessed" just for being alive.

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Copyright 2013 Thomson Reuters. Click for restrictions.

By Marshall Allen, ProPublica

I was recently browsing through the nearly 200 stories we’ve compiled with our Patient Harm Questionnaire, when I was reminded again of a troubling truth. Many of the people who suffer harm while undergoing medical care do not file formal complaints with regulators. The reasons are numerous: They’re often traumatized, disabled, unaware they’ve been a victim of a medical error or don’t understand the bureaucracy.

That’s a problem for those individual patients and for the rest of us. There are many places to complain: a state licensing agency; a professional licensing board that monitors doctors or nurses; the Joint Commission, which accredits hospitals or a Medicare Quality Improvement Organization. But if there are no complaints, there are no independent investigations, and that means no outside accountability for providers who may have made mistakes, and no public inspection reports that documents the case -- assuming an agency makes reports public, which is not always the case. It’s a collective problem because patient safety flaws that remain hidden, if they are not corrected, may be repeated.

We have staggering estimates of the number of people harmed while undergoing medical treatment. A review of medical records by the U.S. Health and Human Services Department’s inspector general found that in a single month one in seven Medicare patients was harmed in the hospital, or roughly 134,000 people. “An estimated 1.5 percent of Medicare beneficiaries experienced an event that contributed to their deaths,” the IG found, “which projects to 15,000 patients in a single month.”

But there’s no central system in place to tally and track these events. There’s no way to know when and where patients are being harmed or to tell if the problem is worse in one place than another.

It’s not like keeping track of patient harm is a new idea. More than a decade ago the Institute of Medicine’s landmark “To Err Is Human” report called for a national system to capture cases of serious harm to patients or death. The report said accurate reporting provides accountability and knowledge that leads to learning. That’s information that could save lives.

“You really can’t improve what you don’t measure,” said Dr. Julia Hallisy, president of the Empowered Patient Coalition. “How do you know where to focus your improvement efforts if you haven’t measured what’s happening in the first place?”

Efforts at the state level appear to be falling short, according to federal inspectors. In many states, hospital are required by law to file a report every time a patient suffers unexpected harm -- often called  “sentinel” or “adverse” events. But a July report by the HHS inspector general’s office found that only 12 percent of harmful events identified by the office even met state requirements for reporting them. Compounding the problem: Hospitals themselves only reported 1 percent of the harmful events.

We found something similar when I was a reporter in Las Vegas. We used hospital billing records to identify 3,689 cases of patient harm at the city’s hospitals in a two-year period. Each of those cases would fit the state’s definition of a “sentinel event,” meaning the hospitals were required by law to report them. Yet in the same time period they reported to the state only 402 sentinel events.

The federal Agency for Healthcare Research and Quality is now accepting public comment about a proposed program to encourage consumers to complain about harm suffered while undergoing medical care. The goals include collecting information in a common format, developing prototype methods for gathering information on the phone and Internet and creating a follow-up questionnaire for medical providers. Patients will be asked what happened, who was involved and for permission to follow up with the providers involved in the event.

I recently referred the 1,000 members of the ProPublica Patient Harm Facebook Group to a story about the proposal in The New York Times. Many members of the group have suffered harm firsthand and filed complaints, so the article created lively discussion: 

• Robin Karr said that based on her experience, she’s skeptical about reporting harm directly to the government “but not without hope” about the proposed program.
• Debra Van Putten said she knows many people who have filed complaints about harm they suffered, but little came of their efforts. Patients want more than mere acknowledgement, she said. They want accountability for whoever is responsible.
• Martha Deed said there are so many barriers to a patient reporting harm -- emotional trauma and physical disabilities, feeling intimidated by providers, social pressure not to complain -- that a passive questionnaire is unlikely to elicit responses. Instead, the patient harm information should be gathered in a way that’s standardized, she said, like the national survey that’s administered to recently discharged hospital patients that has results publicly reported on Hospital Compare.

That’s food for thought for those developing the program. Official public comment is due Nov. 9 and can be sent to Doris Lefkowitz, the AHRQ reports clearance officer:doris.lefkowitz@AHRQ.hhs.gov.

We’d also love to hear your comments. How do those of you who work in the medical field feel about this type of reporting system? Patients, what do you think about it? And what would you recommend as characteristics that would be essential to such a program?

This article first appeared on ProPublica.org. 

By MyHealthNewsDaily staff
MyHealthNewsDaily

Everybody lies — even doctors. 

A new study finds 11 percent of doctors say that they have told a patient or a child's guardian something that was not true in the past year, and about 20 percent say they have not fully disclosed a mistake to a patient because they were afraid of being sued.

The results also show 34 percent of doctors surveyed did not "completely agree" that physicians should disclose all significant medical errors to affected patients. Instead, these doctors said they only somewhat agreed, or disagreed.

"Our findings raise concerns that some patients might not receive complete and accurate information from their physicians," the researchers write in the February issue of the journal Health Affairs. The findings also question whether patient-centered care — which is a philosophy of medicine that respects the preferences, needs and values of patients — is possible without more openness and honesty, the researchers from Harvard Medical School said.

While the ultimate effect of such untruths is not known, they could make patients "less able to make health care decisions that reflect their values and goals," the researchers said.

To be fair, the researchers acknowledged not knowing the circumstances under which physicians lied, and communication regarding health issues can be complex. Physicians must often wade through conflicting and confusing information as a case goes on. Telling a patient something that turns out to be wrong might not be helpful, the researchers said.

More research is needed to better understand when and why physicians feel justified in a lapse of honesty.

Dr. Arthur Caplan, a medical ethicist at the University of Pennsylvania and msnbc.com contributor, told the Associated Press that to withhold a mistake is "inexcusable," adding that a physician's "care now has to be different because of what happened."

In a poll for msnbc.com, Truth On Call asked 100 physicians, including those in family practice, cardiologists and neurosurgeons if they've ever kept a serious medical mistake from a patient. Twenty one percent admitted they kept an error from the patient, 55 percent say they disclosed the mistake and 24 percent say they've never made a serious medical error.

 Responses differed greatly by specialty, Truth On Call found. Five percent of the 34 family practitioners polled said they made a mistake but kept mum, 47 percent said they disclosed it to the patient and 47 percent said they never made a serious mistake. Among the 33 neurosurgeons polled, 25 percent said they withheld a mistake, while 69 percent told and six percent said they never made a crucial error. And, among the 33 cardiologist polled, 33 percent said they didn't tell the patient about the mistake, while 50 percent told and 17 reported they've never made a mistake.

The Harvard researchers surveyed close to 1,900 physicians from a broad range of specialties about their agreement with the principles outlined in the Charter on Medical Professionalism, a charter endorsed by more than 100 professional medical groups worldwide.

While the majority of doctors agreed that physicians should "never tell a patient something that is not true," about 17 percent did not completely agree.

In fact, 55 percent said that they had "described a patient’s prognosis in a more positive manner than warranted," in the last year, and about 28 percent said they had "intentionally or unintentionally revealed to an unauthorized person health information about one of [their] patients."

In addition, about 35 percent of doctors did not agree with the statement that physicians should " disclose financial relationships with drug and device companies to heir patients."

Women and minority physicians were more likely than white, male doctors to say they agreed with the principles of honesty and openness, according to the study. This may be because, as underrepresented groups in medicine, women and minorities feel more compelled to comply with such professional codes, the researchers wrote.

Some physicians might not tell their patients the whole truth because they don’t want to upset them, worry them or cause them to lose hope, the researchers said.

"Especially in the context of life-threatening illness, physicians might not tell patients the complete truth because of lack of training, time limitations, uncertainty about prognostic accuracy, family requests and feelings of inadequacy about their medical interventions," the researchers said.

Some physicians may also wonder about revealing errors when no harm came of them. However, studies show that "informing patients fully about medical errors can reduce anger and lessen patients’ interest in bringing malpractice lawsuits," the researchers said.

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