Just the other day on out blog we featured the American Medical Association’s response to criticism that the association did little to reduce the number of preventable errors in a medical setting. Today, we’re hearing about a medical resident who has developed a checklist that appears to reduce errors and improve communication when handing a patient from one doctor to another.
Medical errors happen for all sorts of reasons, but some preventable errors occur because of a lack of communication between doctors tasked with caring for the patient from shift to shift. Other times the busy nature of their work doesn’t allow them to go over all the new patients that arrived since their last shift. To combat this breakdown in shift-to-shift communication, a fourth-year resident at Baylor College of Medicine added a new twist to an old procedure.
Residents at Baylor practice the PACT method at the end of each shift, which stands for priority, admissions, changes, and task review. This means doctors should first discuss the patients who need the most care, then go over any new admissions, then discuss the patients who have improved/worsened, and finally they should review any tasks that need to be completed during the next shift. After PACT was initially implemented at Baylor, residents completed more tasks, knew more about patients on their rounds, the discrepancy between junior and senior handoffs diminished, and senior residents had more confidence in junior residents. To build on the PACT procedure, resident Nicole Tapia wanted to see if adding a quick checklist could further reduce medical errors.
“This is something that can be used broadly to improve communication,” said Tapia.
The four item checklist asked physicians to do the following prior to completing the pact procedure: Designate a leader, premark their handoff list, move to a quiet place and to silence all mobile devices. Tapia then had some residents adopt the checklist system, while others continued to practice the PACT method on its own. When comparing the data of 71 PACT and checklist handoffs to 75 PACT alone handoffs, Tapia found on average:
- Handoffs using the checklist were conducted seven minutes faster.
- The checklist group did not have any shift errors, while there were 0.03 errors per shift in the PACT alone group.
- The checklist group reported two PACT interruptions, while the PACT alone group reported four.
- Despite some improvements, the checklist did not appear to increase junior resident patient knowledge. There was no significant increase in the junior residents’ ability to answer nurse and senior staff questions about patients during rounds after using the checklist method.
- Residents noted that high priority patients received more attention using the checklist method but said they preferred discussing patients in order of their location in the hospital.
Dr. Silverman comments
While it appears the checklist isn’t a perfect science, it’s clear that it reduced handoff errors. I’d like to see similar studies that alter or improve on the method, but I commend Dr. Tapia for her interest in reducing medical errors. It’s something we all strive to do, and every little bit helps.
As I mentioned during a previous post on surgical never-events, surgeons go through a similar checklist to ensure each move we make is the right one. This includes double and triple checking before anesthesia, before incision, and before closing the wound. Simply put, checklists and checking your work helps prevent medical errors.
Related source: Medscape
Halloween is right around the corner, and soon little ghosts and goblins will be lining the sidewalks in hopes of finding the house with the king size candy bars. Traversing the neighborhood with friends can be a lot of fun, but it can also be difficult for children stuck in an annoying leg cast. While the cast may slow you down just a bit, the unique thing about a leg cast is you’ve already got a natural prop!
Some kids think a cast will ruin their costume, but check out these costume ideas that are enhanced by a foot cast.
1. Pirate – The pirate costume is always popular, and while kids are quick to grab an eye patch and a plastic sword, sometimes they skip the most unique part – the peg leg! Cover your cast in a brown plastic bag or grocery bag and tell curious folk you lost your leg to a shark or crocodile!
2. Flamingo – Want to rock some hot pink but don’t want to be an injured princess? Go as a flamingo! Flamingos sleep on one leg, so just tuck your leg back after you ring a doorbell and you’ll look the part!
3. Injured Sports Star – Some notable sports stars that are currently out with foot and ankle injuries include Alex Morgan, Robert Griffin, Calvin Johnson, Miguel Cabrera and Kevin Durant. Show the other kids just how dedicated you are to look just like your favorite superstar.
4. Injured Elsa or Anna – Let’s be honest, Frozen costumes are all the rage right now. Even celebrities are dressing up as their favorite Frozen character. Your costume won’t change much, but make up a fun backstory. Maybe Elsa slipped on an ice patch she created, or Anna tripped over Olaf. You choose!
5. Mummy, Frankenstein or Zombie – These probably work best if you can ditch the crutches for a walking boot, but Frankenstein, mummies and zombies have a distinct style of walking. Frankenstein has a robotic style, while mummies and zombies shuffle and limp around. If you really get into character you’ll probably forget you’re even injured in the first place.
Are you going Trick or Treating in a cast? Tweet us you Halloween costume @AnkleFootMD and you could end up on our blog!
A report from the consumer group Public Citizen suggests that medical malpractice errors are a major problem in healthcare industry, and while no doctor will argue that the current system is perfect, the American Medical Association suggests the group’s simplistic statistical analysis doesn’t tell the full story.
The Public Citizen report notes that while medical malpractice payments are trending downward, they claim there is no evidence that medical malpractice errors are occurring at a lower rate. Instead, they say physician demand for payment caps are the reason total payouts are down.
“An essential first step would be for the AMA and other leaders to commit the same level of energy to eradicating avoidable adverse events in hospitals as they have in pursuit of the laws to limit doctors’ liability for those adverse events,” the report included.
AMA Hits Back
Not surprisingly, the American Medical Association did not take the “recommendations” lightly. An AMA spokesperson said the report was generated using “inherently flawed” data from the National Practitioner Data Bank.
“The Government Accountability Office has determined that the NPDB is riddled with duplicate entries, inaccurate data and incomplete and inappropriate information,” the spokesperson noted.
The AMA spokesperson also said Public Citizen neglected to exclude the 65 percent of medical liability claims that were “dropped, withdrawn or dismissed.” Defending dropped or dismissed claims accounted for 38 percent of the total defense costs, the AMA spokesperson noted citing data from the Physician Insurers Association of America.
“Less than 10 percent of the medical liability claims were decided by a trial verdict, and the vast majority of them – 89 percent – were won by the physician defendant in the case,” the spokesperson concluded.
As to the notion that the AMA is focused more on defending lawsuits than preventing them in the first place, Douglas Merrill, MD, of Dartmouth College, said that’s simply not true. In fact, he claims the relatively constant number of medical errors may be due to more reports coming from the physician’s end.
“As an industry, healthcare has been striving for over a decade to create a climate of self-disclosure in the certainty that this would help discover trends in risk and safety that can be addressed at a systems level and preventive changes made earlier,” said Merrill. “Thus, a greater number of errors reported is potentially good news.”
Merril ended by saying that relying on insurance data to assert that the healthcare industry is failing to do their part in preventing malpractice errors is a poor assessment.
“No credible caregiver would say that healthcare can’t be improved, whether regarding access or quality, or error rates. However, no credible healthcare analyst would use insurance data as an accurate descriptor of the need for or the intensity of those efforts.”
Dr. Silverman comments
As I’ve said before, statistics don’t lie, statisticians do. The organizations that complain about a drop in malpractice payments are consistent about one thing, they only measure the data that helps their cause.
The AMA’s response is right on.
Related source: Medscape
Detroit Tigers first baseman Miguel Cabrera underwent successful surgery last week to have pesky bone spurs removed and to correct a navicular stress fracture. The team hopes their slugger will be fully healthy by the start of spring training, but they held off on suggesting a timetable until they saw how his foot responded to the operation.
“There is no time frame,” said Tigers president and general manager Dave Dombrowski. “What they are going to do is wait until he’s re-evaluated after the three-month period and then kind of go from there.”
The Tigers had initially stayed mum on whether or not Cabrera would undergo offseason surgery, but we weren’t surprised. As I mentioned in a previous blog about Cabrera’s bone spurs, surgery was the smart option.
“It’s clear that Cabrera needs to go under the knife this offseason. If Cabrera wanted to ride off into the sunset this offseason and hang up his cleats, he could probably get away with just resting his foot. If he wants to return to Triple Crown form, he’s going to need to have the spur and any underlying conditions addressed. He needs to have the foot surgically fixed if he wants to play pain free next season. Rest could help in the short term, but the problem will surface again during another long season if the root cause goes untreated.”
What’s interesting is that Cabrera also underwent surgery for a stress fracture of the navicular bone. Odds are this also played a role in the discomfort he dealt with near the end of the season. I have also discussed navicular fractures in the past, and much of the information can be applied to Cabrera’s situation.
Most initial X-rays are normal and unless there is a high degree of suspicion, patients often do not get an early diagnosis. The longer the true issue goes unnoticed, the more problematic it can become.
Team officials didn’t announce if they knew about the navicular fracture when they discovered Cabrera was dealing with bone spurs, but the fracture has to be more concerning than the spurs. If the problem doesn’t heal correctly, Cabrera could develop arthritis in his foot, and it has the potential to affect him for the remainder of his career. I’ll be following his rehab over the next few months to see how his foot responds to the surgery.
Related source: Detroit News
A 71-year-old man who had already survived a bout with prostate cancer thought he was going to lose his foot when doctors informed him about a new cancer that had developed in his heel.
Doctors at St. Vincent’s Hospital in Melbourne informed Lee Chandler that their only course of action involved surgery, and that operation involved amputating his leg below the knee.
“I was prepared before I went,” said Chandler. “I though if I’ve gotta lose it, I’ve gotta lose it.”
A scan of the cancerous heel area uncovered that there was simply no current or functional prosthetic that could be inserted after the cancerous bone was removed. But, just because something doesn’t yet exist, doesn’t mean it can’t be made. By combining modern medicine and advanced technology, scientists were able to generate a 3D model of a functional prosthetic designed specifically to address the rare form of cancer in Chandler’s heel. They then used the design to print a titanium replica heel.
Professor Peter Choong said all the functions of the heel had to be accounted for when designing the custom piece.
“What we try to do with the new prosthesis is simulate the sorts of functions that his bone would have,” Choong said. “First of all the shape, strength, also parts of it have to be nice and polished where it has to run or articulate, as we say, against different other bones. For example, you have the shin coming down on to it, you have the foot bones in front of it and they provide very complex surfaces that you could not normally match with.”
Chandler underwent the innovative operation in July, and he was discharged from the hospital 12 days later.
“I’ve got no irritation or pain or anything from that. It just fits perfect, I couldn’t ask for anything better,” Chandler said of the printed heel. “I don’t know if I’ll be kicking a football or not but I’ll be getting around.”
Dr. Silverman comments
This is truly a wondrous combination of medical knowledge and technological advancements. Procedures are becoming safer, and patient livelihood is always being improved with new technologies.
I believe we’ll be hearing of similar stories in America in the not so distant future.
Related source: ABC News
In an effort to give people a better understanding of portion size and dietary recommendations, scientists are suggesting calories counts on packages may soon be replaced by the exercise duration needed to burn off the food.
The authors of a study published in the American Journal of Public Health found that teens made healthier dietary choices when presented with the new caloric exercise information. To test their hypothesis, researchers presented dietary information in four different ways.
• Absolute calories
• Miles of walking needed to burn off the calories
• Minutes of running needed to burn off the calories
• Teaspoons of sugar
The four caloric variations were posted in the soda sections of local corner stores. Teens were then asked to go into the store and purchase a beverage of their choosing. According to researchers, when presented with the number of minutes of walking needed to burn off the beverage, more teens opted for a smaller sugar-sweetened beverage, a diet beverage, water or skipped the beverage altogether.
Researchers were encouraged by the findings, but noted that their study was limited to African American youth – a group at high risk for obesity and diabetes.
“Overall, we found that providing easily understandable caloric information might be an effective strategy for lowering calorie intake from sugar-sweetened beverages among low income Black adolescents and encouraging increased water and diet soda purchases,” the authors wrote.
The authors also wrote that even if teens didn’t choose a healthier option when presented with the exercise information, participants noted that they had a better understanding of the health impact based on the information than if they were simply given total calorie counts.
Dr. Silverman comments
This study’s results are consistent with similar studies that suggest people make smarter food choices when presented with easy to understand information. While not everyone may know exactly how many calories they should consume each day, it wasn’t long ago that even this information wasn’t present on fast food and restaurant menus. Now, all it takes is a glance at the menu to realize that Southwest Chicken Salad with Ranch dressing is just as bad for you as that Double Cheeseburger.
But these researchers are trying to make it even easier for people to understand, and it appears to be having the intended effect. 180 calories may not seen like a lot for a can of soda, but if it takes 45 minutes to walk that off, maybe you’ll be more inclined to opt for an Aquafina.
I would like to see the FDA make the next move on this. Surely product makers won’t put this information on their sodas if it has a chance to hinder sales, so it’s time for the government to take a closer look at the health impact this could bring.
Related source: Medscape
For their study, researchers hooked 18 men and 18 women in their 20s up to a machine designed to capture leg spasm and movement. Participants were asked to resist downward pressure from a mechanical arm, but half the group was subjected to a loud beep prior to the downward pressure, while the other half heard no sound. Researchers say the sound was equivalent to the revving of a loud motorcycle engine.
Interestingly, those participants in the noise group exhibited significantly more muscle stiffness during the resistance and bend tests compared to those in the no beep group. Researchers also noted that muscle activity and joint stiffness reduced as the startled response subsided.
Researchers wrote that higher initial stress followed by markedly reduced stiffness likely indicates a disturbance in neuromuscular control that can lead to abnormal stress and unintentional injury. Considering there are an estimated 250,000 ACL sprains and tears in the US every year, it’s not unreasonable to suggest that at least some of them occurred as a result of a loud or unexpected noise.
The researchers noted that the beep used in the study may not compare to loud sounds during athletic competitions, and an athlete can reasonably expect to hear a whistle or a buzzer at certain intervals during the matchup. Instead, they say car horns, unexpected sirens or a nearby shout are the most likely cause of noise-induced injuries.
Dr. Silverman comments
This study is interesting because it focuses on how our brain’s reaction to an unexpected occurrence affects the rest of our body. A sudden jolt or flinch is your body’s way of going into “defense mode,” but if you’re running or playing a sport, that instantaneously reaction could cause major issues.
Related source: Wall Street Journal
Morgan exited Friday’s 5-0 win after colliding with a Guatemalan player in the 37th minute. As you can see in the video below, Morgan’s ankle twisted when she was hit from the side by a defender.
A subsequent MRI revealed no further damage, but the ankle sprain is expected to keep her sidelined for 4-6 weeks. Head coach Jill Elias said other members of the team will have to step up to fill the void left by Morgan.
“We certainly feel for Alex and of course having her go down is a big loss to our team, but as I’ve often said, one of our strengths is depth and everyone on the roster is prepared to step up,” said Ellis. “After talking with our medical staff and Alex, we all agreed that the best course of action for her is to head home to minimize travel and get into an environment where she can totally focus on recovery.”
The United States is 2-0 in group play and is considered the favorite to win the tournament and clinch a spot in the Women’s World Cup next summer. Morgan said she’s disappointed by the injury but knows the main goal is to be healthy for the World Cup.
“It’s unfortunate timing, but I know my teammates will take care of business and qualify for the World Cup and I’ll be watching from my couch,” Morgan said. “I have plenty of time to get healthy with a longer break coming up for the team so my job is to focus on the rehab and get back healthy as soon as I can.”
Dr. Silverman comments
Despite what the Youtube video is titled, Morgan did not break her ankle during the play, which is somewhat surprising based on the force and twisting that occurred.
This type of ankle injury is classified as an ankle inversion. The lateral ligaments on the outside of the foot are stretched, and the timetable for return depends on the severity of the sprain. Based on the video evidence and the fact that an MRI revealed no structural damage, 4-6 weeks sounds about right.
While Morgan should have no problem healing with plenty of time to spare before the World Cup, there are some concerns about her ankle health. She missed seven months after injuring the same ankle last fall. When speaking about that injury, Morgan noted that the previous injury was not a typical sprain, saying she suffered a bone bruise that eventually led to a stress reaction. She ultimately had to be completely non-weight bearing for some time. She blamed herself for the improper care, but the doctors will certainly want to make sure Morgan isn’t dealing with a larger issue. They’ll also want to ensure she sticks to her rehab regimen.
Morgan is a bright young star for the women’s national team, so I hope she’ll be completely healthy when the World Cup rolls around. The team will certainly need her.
Related source: USA Today, Bleacher Report
For their study, researchers asked 24 runners who ran faster than an 8:00 mile to select one of three running styles; Flexed (Some forward lean), Erect (Essentially straight trunk) or self-selected (No intentional style). Researchers measured the reaction forces and stress levels exhibited by each group and uncovered:
• In the self-selected group, the runners with the least forward lean experienced the most patellofmoral joint stress.
• The difference was even more pronounced when comparing the flexed group to the erect group.
• No groups said they experienced pain before or after running, but researchers say the increased knee stress could cause problems over time.
“On average, a 6.8-degree increase in the mean trunk flexion ankle resulted in a 6.0 percent decrease in peak [patellofemoral joint] stress, whereas a 3.3-degree decrease in mean trunk flexion led to a 7.4 percent increase in peak [patellofemoral joint] stress,” researchers noted.
Dr. Silverman Comments
The study’s findings are interesting, but it’s nothing new. As I’ve said in previous posts about running, a midfoot strike is generally preferred to a heel strike pattern. Not only does a heel strike cause more stress to the knee, you’re also at a heightened risk for a heel bruise or calcaneal fracture.
You are more likely to run in a heel-strike pattern if you have an erect trunk. Leaning slightly forward will naturally push you towards a midfoot strike as your feet adjust to your new center of balance. That’s not to say a slight lean will automatically make you run with a midfoot strike, but the study appears to show that even in heel strikers some of the knee stress can be avoided by repositioning your trunk.
Another thing to keep in mind when running is to keep your hips facing forward. Running with a moderate to significant hip twist puts unneeded stress on your lower half.
In the end though, everyone has their own running style, but if you find yourself dealing with knee pain after your run, try leaning forward a bit during your next jog.
For their study, researchers fed adolescent lab rats solutions of sugar or high fructose corn syrup in concentrations comparable to a 12-ounce soda. Researchers found that the rats that drank large quantities of the liquid were more likely to:
- Exhibit memory problems
- Experience brain inflammation
Adolescent rats who were not fed the sugary solution were less likely to develop the above conditions, but the truly interesting findings come when comparing adolescent rats to adult rats. Researchers said that adult rats who were fed the sugar solution did not have issues with memory loss or brain inflammation, suggesting the excess sugar may be more damaging to younger brains.
“The brain is especially vulnerable to dietary influences during critical periods of development, like adolescence,” said Scott Kanoski, a corresponding author on the study.
Researchers used a spatial memory maze to see how sugar or its absence affected a rat’s memory. After completing the maze, the adult and adolescent mice in the sugar group were fed the sugar solution and then placed back in the course. The adolescent mice that did not receive the solution were given a similar interval between retrials. On the subsequent attempts, the adolescent rats that were fed the sugary solution preformed far worse than the other two groups.
Researchers believe neuroinflammation in the hippocampus may be to blame, as the hippocampus is part of the temporal lobe that controls memory formation. Adolescent rats in the sugar group were found to experience more hippocampus inflammation than the other two groups, and similar hippocampus degeneration has been associated with condition like Alzheimer’s and dementia in humans.
“Consuming a diet high in added sugars not only can lead to weight gain and metabolic disturbances, but can also negatively impact our neural functioning and cognitive ability.” Kanoski concluded.
Dr. Silverman comments
The plain and simple truth is that excess soda consumption is awful for your body. High schoolers who chug Mountain Dew to stay up late cramming for a test are probably doing more harm than good.
Practice healthy routines like a balanced diet and a good night’s rest. You’d be amazed what your brain can do when it’s fully rested.
Related source: Dornslife.USC.edu