I got a comment from one of my readers in response to a recent post, QTc Prolongation and Psychotropic Medications: New Reviews – The Practical Psychosomaticist:
Been there! Hospitalized 2 yrs ago for prolonged QT syndrome and prior to surgical implantation of a defibrillator scheduled for the following day had the presence of mind to request an electrophysiology consult which resulted in psych meds being found as the culprit…..surgery averted. Funny how the med prescriber and pharmacist failed to mention this possibility. Thank heaven for the astute specialist who checked my med list thoroughly.–from WELL CALL ME CRAZY | This WordPress.com site is about hope, trauma, hypocrisy, and transformation.
This is really about patient safety, and a quote from an article in a past issue of Annals of Internal Medicine probably fits:
“To be a good doctor, sometimes you must envision yourself as slightly stupid.”–a quote from a physician friend of the author, the parent of a very sick child, the cause of whose medical illness led to delirium and multiple complications, a long hospital stay, and thankfully, eventual recovery. The author goes on to say, “…a physician who acknowledges his or her limitations is far preferable to one who presents a façade of omniscience.” .
I’m indebted to one of our Medical-Psychiatry residents for alerting me to recently published articles about patient safety research in the Annals of Internal Medicince (subscription publication though some articles are free) mentioned below.
Emphasizing safety reminds me of my latest visit to our emergency room in the middle of the night after a call from one of the psychiatry residents about a patient he was evaluating. The patient had said something worrisome to the emergency room physician on duty, then reported something completely different to the resident, and finally revealed something alarming to me that no one else that night had thus far heard. I had not elicited the additional history; it was simply volunteered. It led to a completely different treatment plan, which might have saved lives. Sometimes it’s better to be lucky than good. I think it was vital we all took the time to listen and be open to any nuance leading to a change in how we helped the patient. I slept better when I returned home that night not just because of our heightened vigilance in the emergency room–but also because of our willingness to suspend judgment for a little while and patiently wait for the real crisis to be uncovered.
When physicians forego this vigilance combined with patience, disasters can occur. An interesting graphic novel presentation of a fictional case of a missed medical diagnosis resulting in a patient’s death was published in the March 5, 2013 issue of Annals of Internal Medicine . Sadly, this kind of mistake is all too often not fictional.
The same March 5th issue of Annals of Internal Medicine contains a wealth of information about recent reviews of measures doctors and hospitals can take to optimize patient safety in hospitals. Many of them are steps that experts encourage we adopt right now. Although adopting multicomponent programs for preventing delirium is not one of them (due mainly to many of the studies being limited by various sources of bias), there is still enough evidence showing we can do much more than we’re doing now .
It is vital for individual physicians to be willing to assume leadership roles in advancing patient safety research and implementing safer clinical practice models. We have to be willing to “know the way, go the way, and show the way”. This is despite the observation that the less the physician is involved, the better the implementation of many patient safety promotion programs:
“Another lesson from these reviews is the importance of the system of care provided by a health care team. Some of the most successful programs have been those that minimize the roles of the physicians and maximize those of nursing or respiratory staff. It is ironic but often the case that the less the physician is required to do in the course of maintaining a bundle of care, the more likely it is that protocols will be followed and outcomes improved. As health care insurance coverage increases and the population grows with increasing amounts of chronic illness, the roles of nonphysician health professionals, including nurses and pharmacists, to provide quality and timely care can only expand. They are essential parts of an effective team that requires physicians to understand team function and their own leadership roles. Teams will be central to newer delivery models.” .
That means humility, patience, and collaboration amongst nurses, patients, pharmacists, physical and occupational therapists, social workers, learners, neuropsychologists, and other physician specialists will be critical components of high quality patient care delivery. No single specialist should assume total responsibility for continuous improvement of patient care. Ego has to be sacrificed to cooperation. That will be challenging for physicians, long accustomed to thinking of themselves as being unique. We have something special to offer–the ability to share accountability for patient safety.
1. Mehler, G. and A. Zwang (2009). “Medical Mystery, Medical Humility.” Annals of Internal Medicine 151(4): 283-284. Annals of Internal Medicine | Medical Mystery, Medical Humility
Our learning experience began when Grace became listless after a bout of vomiting that we assumed was caused by a minor, school-acquired virus. Her continued vomiting quickly dehydrated her, causing her to be hospitalized twice in the next few days. After her second return home, when she finally seemed to be improving, she was hospitalized a third time.
2. Green, M. J. and R. Rieck (2013). “Missed It.” Annals of Internal Medicine 158(5_Part_1): 357-361. Annals of Internal Medicine | Missed It
3. Reston, J. T. and K. M. Schoelles (2013). “In-facility delirium prevention programs as a patient safety strategy: a systematic review.” Annals of Internal Medicine 158(5 Pt 2): 375-380.
Delirium, an acute decline in attention and cognition, occurs among hospitalized patients at rates estimated to range from 14% to 56% and increases the risk for morbidity and mortality. The purpose of this systematic review was to evaluate the effectiveness and safety of in-facility multicomponent delirium prevention programs. A search of 6 databases (including MEDLINE, EMBASE, and CINAHL) was conducted through September 2012. Randomized, controlled trials; controlled clinical trials; interrupted time series; and controlled before-after studies with a prospective postintervention portion were eligible for inclusion. The evidence from 19 studies that met the inclusion criteria suggests that most multicomponent interventions are effective in preventing onset of delirium in at-risk patients in a hospital setting. Evidence was insufficient to determine the benefit of such programs in other care settings. Future comparative effectiveness studies with standardized protocols are needed to identify which components in multicomponent interventions are most effective for delirium prevention. Annals of Internal Medicine | In-Facility Delirium Prevention Programs as a Patient Safety Strategy: A Systematic Review, free article.
4. Shine, K. I. (2013). “Patient Safety Strategies: A Call for Physician Leadership.” Annals of Internal Medicine 158(5_Part_1): 353-354. Annals of Internal Medicine | Patient Safety Strategies: A Call for Physician Leadership
More March 5, 2013 issue of Annals of Internal Medicine articles: