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Unaccountable: Review Of Marty Makary's Book

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Some people believe that hospitals have a history of secrecy and “cover ups. ” Not really the type of affiliation you want to have as a medical professional. As a nurse, I have often been asked “what horrors have you seen? what’s the worst thing that’s happened?” These shouldn’t be questions that come to mind when thinking of nurses, doctors and hospitals, especially when you may very well end up a patient or have a family member as a patient one day. Wouldn’t you like to know what hospitals have “horror stories”, horrible doctors, and ones you want to avoid? On the other hand wouldn’t you want to know who the nice doctors are and where you want to go should the need arise. Transparency is the answer. Businesses all over America are held accountable for their actions and results-by law-and can be fined or jailed when the public is misled by their performance. Hospitals, however, have little incentive to participate in programs of transparency. (Makary, 2012) They self-monitor their infection rates and do their own “self-reporting” with no accountability. This can often lead to a patients being mislead instead of being informed for better and safer decision making. Far worse is that hospitals can, at times, be rewarded for these errors of omission.

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The problem lies with the standardization process. How do we make them accountable and true transparency attainable with unfair and inaccurate data reporting? As nurses, we play a key role as advocates for patients and the hospital choices they can make. Therefore, nurses are extremely important in the “transparency movement” that is currently taking place in American healthcare systems. Forward- thinking doctors and hospitals that they work for are leading the way to transform helathcare as we know it. They have come up with programs to screen and help impaired doctors and nurses, created new standards of accreditation and bedside care and are pushing for full public reporting of patient outcomes to name a few. (Makary, 2012) In order to create a fair and equal standardization process, they have found several ways that can be used to measure and track hospital performance with concrete proof.

  1. Bouncebacks. These are re-admissions within a 90 day perod of the patients discharge. What are the reasons for their “bounceback?” Was the stay in the facility not long enough to properly “heal” them to the point they needed to be? Were they not given proper discharge instructions? Did they understand the instructions that were given to them?? Is there a complication to their healing for another unforeseen reason?
  2. Complication Rates. “An unexpected adverse event that develops during or after medical treatment or procedure. ” (Makary, 2012) Typically these complications consist of or are due to bleeding, wound development or wound infections, GI/malnutrition, respiratory, cardiovascular, kidney or neurological issues.
  3. Never Events. These are events that occur that should NEVER EVER happen in a hospital. These are different from a complication in that the never event is avoidable. For example, a sponge or surgical instrument that is left in a patient, a wrong operation on a wrong patient, or the wrong operation on the correct patient. Another never event is the death of a healthy patient during an elective surgery. These kinds of events happen a couple times a year and with the transparency movement, these events wouldnt be swept under the rug in a lawsuit with a monetary settlement, but instead would be reported and could potentially lead the hospital into a public relations problem. In 1996 JCAHO implemented a sentinel event policy. They hoped it would help hospital s improve patient safety and learn from these events. The events include unexpected deaths and serious physiological or psychological harm to patients. ( Knowles, 2018) In 2017 the 10 most frequently reported sentinel events reported were unintended retention of a foreign body (116), fall (114), wrong-patient/wrong site/wrong procedure (95), suicide (89), delay in treatment (66), other unanticipated event such as asphyxiation, burn, choking on food, drowning or being found unresponsive (60), criminal event (37), medication error (32), operative/post op complication (19) and self-inflicted injury (18).
  4. Safety-Culture Scores. These are surveys given to workers regarding the facility in which they work. Questions such as would you have an operation here? Are you comfortable enough to bring to attention a safety concern you may have? Does the teamwork here promote what is right for the patient? What hospital would you choose to go to if you needed to? If the public had access to their responses and data, this would incentivize hospitals to invest in their workers, their culture and the promotion of safety and teamwork. The National Quality Forum’s Safe Practices for Healthcare and the Leapfrog Group both mandate hospitals to regularly assess their safety culture. Links were made between poor staff perception of safety culture to increased error rates in hospitals.
  5. Hospital Volumes. Hospitals should have to report patient with particular medical conditions and how many of each type of surgery they perform annually. Also are the surgeries performed minimally invasive or traditional open surgeries. What are the percentages of each? This would educate consumers on to what hospital has the knowledge and experience they’re looking for. Also, are people still going to the hospitals for the elective procedures? The rise of high-deductible health plans is starting to cut into hospital admissions and threaten record hospital margins boosted by the Affordable Care Act. Patients avoiding elective surgeries and other procedures because of skyrocketing out-of-pocket costs were cited by hospital chains as a primary cause of softening hospital volumes.
  6. Transparent Records, Open Notes, and Video Recordings. This is pretty self-explanatory, but very important. Patients would have full access to their records, notes and video recordings of their surgeries and treatments. With the era of electronic health records and cell phone apps for everything we will soon be able to pull up our medical records, medications, lab results, and doctors appointments at the click of a button. Some doctors and health professionals feel that the sharing and open notes would create more worry amongst their patients and the creaton of more patient questions. However, others feel the benefits will outweigh the downside. Error prevention, such as wrong medication on a list, or lab results for the wrong patient, might easily be more discovered with a patient and/or family members access to records, notes or recordings. Adversely, these could potentially expose many more hospitals or doctors to more malpractice suits. There are pros and cons to the openness of these innitiatives. Much like police dashcams or body cams, they could also protect the doctor or hospital from faulty law suits. Medicine and its advances need data to improve and to move forward and evolve. Hence the terms “evidence-based medicine. ” Medicine depends on the public and therefore the public must demand transparency. Statistics, rates, cultures of hospitals, measurable standards of care expected. We as consumers must demand accountability. Empowering patients with information can lead to an econmic solution for our healthcare system. Having worked for many years as a nrse, I’ve seen “bouncebacks” from an open heart surgery due to a nurse who was rushing through discharge instructions with their patient because she was understaffed and had too many other patients that also needed her. Complications from wounds that lead to sepsis and at times event death. Never events such as a full bag of heparin being given to a patient because the IV pump was set incorrectly.

At the facility I worked we filled out the Safety Culture Surveys. I often wondered what happened with the results. I have heard co-workers say “Well yes our hospital is great for this, but if you need XYZ, go to. . . ” This was due to their working for doctors and surgeon that they didn’t trust or that they knew that they were that patients best chance at a successful and safe surgery, procedure or test result. My OB/GYN specifically told me to go to a certain hospital because she had her children there and trusted the surgeons and other doctors there. The anesthesiologist she used with my surgery was the same one that she trusted her own child to when she needed surgery. On taking a tour of multiple hospitals in this area, they had started reporting how many babies they delivered annually, how many were c-sections, of those c-sections how many were elective versus emergent, as well as infant or maternal death rates.

As a nurse and as a patient, I have seen the inner workings of healthcare as well as experienced it. I have seen good and bad doctors, nurses, aides, custodial staff and dietary staff. I’ve also seen things covered up for personal reasons as well as liability fears. I hope that with all the new evidence that points toward reducting errors and deaths that new regulations and laws will be passed to help patients. Having done some research, I have seen that there are new policies and procedures being introduced and implemented to help with the transparency movement. I hope that as more and more are adopted the evidence will show the positives and allow for more to come to fruition. As I journey towards my MSN in Nurse Education, I hope that I can become part of the advancements of medical transparency and the push towards the right decisions for my patients as well as those I’ll be educating.

15 July 2020

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