As reported by The Wall Street Journal, NPR and other media outlets, consumer groups gathered in Washington, DC last week to urge Consumer Product Safety Commission chairwoman Inez Tennenbaum to mandate new safety features in table saws.
The push comes as new data reveals the staggering frequency of table saw accidents and as new technology makes such accidents avoidable.
Recently, the CPSC released data showing that 40,000 people annually are injured by table saws, up twenty-five percent from a decade ago.
Meanwhile, a new, patented flesh detection technology – sold exclusively by saw manufacturer SawStop – has made such injuries avoidable. The SawStop technology uses a tiny electrical current to stop saw blades spinning at 5,000 rpm within milliseconds of their coming in contact with electrically conductive surfaces like human skin (human flesh, which is mainly made up of water, is much more electrically conductive than wood).
Adding SawStop technology to power saws adds approximately $100 to their cost. But power saw manufacturers, such as Black & Decker, Bosch, Ryobi, Delta and Rigid have not licensed the patented flesh detection technology or offered an equivalent in their saws.
Table saw injuries can be gruesome and life-altering. One of the table saw accident victims who went to Washington, DC to urge CPSC to do something was Adam Thull, who a year ago suffered a table saw injury where the blade cut through the bone of most of his forearm. Thull has already had five surgeries and has six more to go.
Now consumer advocates will have to wait-and-see what the CPSC does.
To read prior blog posts on SawStop, you can click here, here and here.
Full Disclosure: The Law Office of Alan H. Crede, P.C., represents personal injury victims using saws not equipped with SawStop.
“We train, hire and pay doctors to be cowboys. But it’s pit crews people need.” – Dr. Atul Gawande
The commencement speaker who addressed this year’s graduating class at Harvard Medical should be a familiar figure to readers of this blog. It was one of the blog’s heroes – Dr. Atul Gawande – he of “checklist manifesto” and “health care cost conundrum” fame.
Although the tone of Dr. Gawande’s address was uplifting, it was not the typical commencement address larded with platitudes and bromides about life; instead Dr. Gawande delivered a clear clarion call to graduates about the future of medicine. Dr. Gawande stated that the task for this generation of doctors – the task which they must carry out if we are to improve health care and make it affordable – is to work together as members of pit crews work together, while applying data-driven best practices.
Dr. Gawande began his address which you can read here (h/t Cal Consumer Attorneys), by noting the explosion in the complexity of medicine in the last century, an explosion in knowledge and technology that outstripped the gains of all the past centuries of medicine combined.
In the 1930s, 40s and 50s, it was possible for doctors to tote around the whole of medical knowledge in their brains. Doctors were cowboys, lone wolfs, rather than collaborators. They didn’t need to know how to play nice or be part of a team because they didn’t need teammates; the sum total of the body of medical knowledge and treatment was at their fingertips, as it was so small.
But as medicine’s complexity has exploded, so too has the number of nurses, specialists and other health care patients involved in a patient’s care. In 1970, 2.5 nurses and doctors participated in the care of the average patient. By the 1990s, the number was more than 15.
As the number of moving parts in a patient’s care increases, the members of a patient’s health care team need to work together like a pit crew. Like pit crews, the members of a patient’s health care team should follow checklists – checklists that have been shown to reduce medical malpractice by forty-seven percent.
The principles doctors should follow in their checklists should be derived from data-driven research of best practices. As Dr. Gawande notes:
People in effective systems become interested in data. They put effort and resources into collecting them, refining them, understanding what they say about their performance.
When you study the data, you find that the most effective health care techniques are not the most expensive. And that fact means that we can afford health care without having to ration it. As Dr. Gawande notes:
The places that get the best results are not the most expensive places. Indeed, many are among the least expensive. This means there is hope–for if the best results required the highest costs, then rationing care would be the only choice. Instead, however, we can look to the top performers–the positive deviants–to understand how to provide what society most needs: better care at lower cost. And the pattern seems to be that the places that function most like a system are most successful.
By a system I mean that the diverse people actually work together to direct their specialized capabilities toward common goals for patients. They are coordinated by design. They are pit crews.
If, in twenty years time, you go to the hospital and the staff’s coordinated efforts resemble the coordinated efforts of a NASCAR pit crew more than a traditional hospital, chances are the care that you receive will be better. And cheaper.
According to a May 16 article in the Boston Business Journal, despite the stellar reputation of many of Massachusetts’ hospitals, you don’t want to be a Medicare patient in a hospital here.
We have nearly a half-dozen medical schools in the Commonwealth, as well as some of the world’s best hospitals, but all of our medical wizardry and brain power appears to be lost on Medicare patients. When it comes to Medicare patients, Massachusetts hospitals’ rate of medical malpractice is two to three times the national average.
Some of the medical malpractice committed on Massachusetts Medicare patients is of the forehead slapping variety. For instance, between October 2008 and July 2010 more than fifteen Massachusetts medicare patients suffered complications after they were sewn up with surgical instruments still inside them. This type of retained surgical instrument medical malpractice is especially egregious as it can be readily avoided by using any manner of new technology, such as tagging surgical tools and sponges with RFID chips.
What is up with prevalence of medical malpractice among Medicare patients? It’s a Massachusetts medical malpractice mystery.
We’ve blogged the work of Tom Vanderbilt before — most recently in our post, “Don’t Drive With A Divorced Doctor In A Pick-Up Truck On Super Bowl Sunday” — and we’re fans of his blog howwedrive.com.
Vanderbilt’s latest is a thought-provoking Slate essay entitled “Little, Yellow, Dangerous: Children At Play Signs Endanger Our Kids.” As Vanderbilt writes, such signs are generally despised by traffic engineers. They take drivers’ attention away from the roadway and – potentially – away from children who might dart into the street. Moreover, much like a “Roadway Freezes” sign in summer, “Children At Play” signage conditions drivers to ignore its warning every time a driver travels through a neighborhood and sees no playing children. Traffic engineers have codified their disdain for “Child At Play” signs in their professional bible — The National Cooperative Highway Research Program — which forbids “Children At Play” signs.
In addition to being ineffective, “Children At Play” signs are also dangerous because they distract us from the hard work that we need to be doing to actually improve safety for pedestrians. Thinking in terms of “Children At Play” warnings or other signage makes us think that the there are quick-fixes for livable roadways.
Really improving the safety of children at play requires a serious reengineering of neighborhood streets. Having a 35 mph posted speed limit is not compatible with children’s safety, as accidents at that speed are very likely to cause a child’s death.
Besides, drivers take their cues not from roadway signage but from the conditions they see with their own eyes. When a highway speed limit is 65 mph, drivers slow down if it’s heavy snow. Likewise, when drivers see a roadway marked with a double yellow line, they feel it’s appropriate to go fast even if it’s a residential neighborhood.
Protecting children from cars requires a lot more than signs. It involves changing the subtle cues that make drivers think it’s OK to speed.
Back in January, I blogged about seven ways to reduce our health care costs without limiting the rights of medical malpractice victims. One of the proposals was to educate patients about whether, according to surgical guidelines readily available through the National Guidelines Clearinghouse, surgery was indicated for someone with their particular condition.
The idea is that some specialists, responding to financial incentives, are wont to recommend surgery in situations even where the professional consensus is that surgery is not necessary. Having patients educate themselves via reading the guidelines might empower them to decline surgery and pursue a less invasive (and more promising) course of treatment than surgery.
Now comes a brand-new study, published in the Journal of the American Medical Association, showing that cardiac surgeons are ignoring evidenced-based guidelines and continuing to perform cardiac stent surgeries on patients who would be more likely to benefit from drug therapies.
In 2007, a massive clinical trial known as COURAGE, published its findings on the relative efficacy of stent surgeries known as Percutaneous Coronary Interventions (PCIs) and drug therapies.
The COURAGE study found that for patients who had never suffered a heart attack, drug therapies (cholesterol-lowering statins, aspirin, blood pressure medications) worked better than the PCI surgery.
In fact, the PCI surgery actually endangered patients who had never before suffered a heart attack because it put them at risk for complications such as stroke, emergency bypass surgery and death while under anesthesia.
The COURAGE study helped establish surgical guidelines that PCI surgery be used only after a patient fails to respond to drug-based therapy.
The JAMA study shows that cardiac surgeons are following the guidelines less than half of the time.
In other words, the majority of patients getting PCI surgery are having surgeries done that are actually contrary to what the research-based guidelines recommend.
Dr. William Borden, the lead author of the COURAGE study, thinks he knows why cardiac surgeons are continuing to order these unnecessary surgeries: surgeons have every financial incentive to order PCI over a course of drug therapy. Drug therapy is cheaper and pharmaceutical companies, not surgeons, profit from pills. As Dr. Borden told a Reuters news reporter, “There are no financial disincentives to avoiding PCI. On the contrary, in a fee-for-service model, physicians are paid for doing procedures.”
We’ve discussed the Peltzman effect before on this blog. The “Peltzman effect” describes a supposed phenomenon wherein the utility of new safety devices – like seat belts in cars – is offset by the new risks that it encourages people to take.
Put seatbelts in cars, the thinking goes, and it will just encourage people to speed, thus negating a lot of the benefit of having seat belts in the first place. Put a new safety guard on a cutting machine and it will just make people more careless.
The Peltzman effect is an important enough result that it is taught in many introductory level economics classes. In fact, the Peltzman Effect is extensively cited in the first chapter of Greg Mankiw’s “Principles of Economics” – the most widely-used undergraduate econ textbook in the country – as an illustration of principle Number Four of the “Ten Principles” of economics, which states, “People respond to incentives.” The passage in Mankiw’s “Principles” suggests that the benefit of Ralph Nader’s work in getting seat belts installed in cars was offset by the greater number of accidents that resulted from people’s driving at higher speeds. For a lot of economists, Peltzman’s work, originally published in 1975, sounded the death knell for the type of consumer crusading favored by people like Nader.
But a new, soon-to-be-published study by economist Bae Yong-Kyun, calls the Peltzman effect into question. (H/t Tyler Cowen). Unlike most previous researchers, Yong-Kyun does not draw upon state-level accident data. Yong-Kyun findings are that mandatory seat belt laws actually cause people to drive more carefully rather than less carefully. The paper finds that the offsetting effects found by Peltzman do not exist when all accidents, including fatal accidents, are factored in.
It may be that it is the Peltzman effect that is unsafe at any speed.
Laser spine surgery centers. You’ve probably seen their pay-per-click ads on google (they advertise a lot through pay-per-click). Do they offer a new, better kind of therapy or is it all snake oil?
According to a recent Bloomberg news story, the surgeries at laser spine surgery centers are more expensive and less safe than traditional spinal surgeries. “[Laser spine surgery] strikes me as somewhat of a scam,” says Jeffrey Arle, a Lahey Clinic neurosurgeon. Arle and other surgeons believe that laser surgery simply offers the same surgeries performed with a different modality, and at a substantial mark-up. Laser spine surgeries often cost twice what traditional spine surgeries cost.
All of this would be fine – it would merely be luxury-branded spinal surgery – if it weren’t for the fact that many laser spine surgeries are unnecessary and the incidence of medical malpractice in laser spinal surgeries so frighteningly high. The number of medical malpractice claims at laser surgery centers is several times the rate at other types of surgery centers.
And many claim that the kind of aggressive marketing of laser spine surgery centers that you see on the web carries over into the operating room – with the surgery being sold to people who don’t need it. At some laser surgery centers, so-called “patient coordinators” are offered bonuses and other incentives – such as trips to the Bahamas – based on the number of surgeries “booked or sold.”
If you’re considering laser spine surgery, maybe you should get a second opinion.
The tragic case of Phoebe Prince, the Northampton, MA teenager bullied into committing suicide, earned national attention and shone a spotlight on schoolyard bullying. It led to criminal charges against the bullies and, last week, the last of the accused teens entered into a plea deal.
None of the teens will be going to jail and there is some public furor over that fact, with many claiming the teens’ sentences were too lenient. (Based on the news accounts that I have read, I have conflicted feelings; my immediate reactions to the appropriateness of the defendants’ sentences vary with respect to the individual defendants and their differing degrees of culpability. Even if some of the teens will escape without carrying a criminal conviction on their record, in this day and age of google footprints each one will, for better or worse, carry these charges with them for life. At any rate, focusing on the on the sentences meted out to the bullying teens neglects the aspect of the case that initially captivated the public: that it seemed almost everyone in town – from teachers to school administrators, parents of classmates and hallway bystanders – shared some degree of responsibility for Phoebe’s death – but, since this diffuse blameworthiness did not fit neatly within the rubric of any criminal offense or civil tort, a lot of wrongdoing will forever go unpunished. One’s heart breaks over what Phoebe’s mother has endured.)
What Phoebe’s case helped illuminate is how serious the problem of bullying can be. It’s not the case that, “Sticks and stones may break my bones”; schoolyard bullying can kill, which is what made the case so surprising to many. And now we have the name and know the face of someone it killed.
After writing my last blog post – on physician-nurse bullying – it occurred to me that bullying also kills in the grownup world of hospitals and emergency rooms, but this problem gets less attention. According to a 2004 study published by the Institute for Safe Medical Practices, seven percent of the nurses surveyed had, within the past twelve months, been involved in a medication error for which doctor intimidation of nurses was at least partly responsible. When seven percent of nurses have within the past twelve months been involved with a medication error attributable to physician bullying, it is a virtual certainty that deaths caused by physician bullying are among the 100,000 deaths caused by medical error each year. But unlike with school-age bullying and Phoebe Prince, most of us can’t name someone whose life was lost to medical bullying.
Phoebe Prince’s death spurred new anti-bullying legislation for which I think we should all be grateful. (It’s about time that we wake up to the reality of child-on-child abuse, the same way that, a generation ago, with the OJ Simpson case, we awakened to the reality of spousal and domestic partner abuse). But deaths caused by doctor-nurse bullying haven’t led to any reforms. Instead, we see states like Florid passing tort “reform” programs that further insulate doctors from the consequences of their actions.
My last blog post was on how breakdowns in communication between doctors and nurses are the main source of medical malpractice in the Emergency Room.
Why are their problems in doctor-nurse communications? The white paper mentioned in my last post lays the blame at the feet of technology: nurses input data into computer systems and doctors don’t check the database – everyone’s communicating virtually and no one is relaying information face-to-face.
But an even bigger reason why doctors and nurses sometimes don’t communicate well is the problem of physician bullying of nurses. Theresa Brown, author and oncology nurse, wrote about the phenomenon last week in a New York Times editorial entitled, “Physician, Heel Thyself.” As Brown writes, “while many hospitals have anti-bullying policies on the books, too few see it as a serious issue.”
MDs engage in a wide range of bullying behaviors. We can all readily call to mind the image of the narcissistic surgeon going into full melt-down mode and throwing a temper tantrum, but, as Brown writes:
“…the most damaging bullying is not flagrant and does not fit the stereotype of a surgeon having a tantrum in the operating room. It is passive, like not answering pages or phone calls, and tends toward the subtle: condescension rather than outright abuse, and aggressive or sarcastic remarks rather than straightforward insults.”
Physician bullying not only takes a psychological toll on nurses but also gravely endangers patient safety. As Brown writes:
“A 2004 survey by the Institute for Safe Medication Practices found that workplace bullying posed a critical problem for patient safety: rather than bring their questions about medication orders to a difficult doctor, almost half the health care personnel surveyed said they would rather keep silent. Furthermore, 7 percent of the respondents said that in the past year they had been involved in a medication error in which intimidation was at least partly responsible.”
Florida and other states want to reduce the costs of medical malpractice by instituting draconian “reforms” of medical malpractice law. It would probably be a lot cheaper, and patients better off, if hospitals simply worked to improve doctors’ civility toward nurses.
As the Harvard philosopher George Santayana famously remarked, “Those who cannot remember the past are condemned to repeat it.” Now Crico/RMF, the insurance company which provides medical malpractice coverage for Harvard-affiliated hospitals, is attempting to learn from past medical mistakes to avoid repeating them.
The results are a white paper on emergency room medical malpractice entitled, “Optimizing Physician-Nurse Communication in the Emergency Department: Strategies For Minimizing Diagnosis-related Errors.” (H/t WSJ Health Blog).
Its findings? Breakdowns in communications between ER docs and ER nurses are the main source of avoidable medical errors in the ER.
To give you a flavor of the types of errors that we are talking about, the report cites an 18-year old who showed up in the ER with fever, chills and mottled skin. The nurse noted the mottled skin – a symptom of a dangerous blood infection – but the doctor never learned of the mottled skin, leading him to discharge the patient with Tylenol, only for the patient to die subsequently of shock and sepsis caused by the blood infection.
If improving communication between doctors and nurses is the key to avoiding medical malpractice in the Emergency Room, it seems to me that medicine should, once again, be borrowing a page from aviation safety methods – such as the “first name rule” – that aviation industry implemented to improve communications between pilots and the rest of the crew. But the Crico/RMF white paper doesn’t float any proposals derived from the principles of aviation safety.
Instead, it talks about “Team Training/Simulation” and professional development for nurses, among other things.
If medicine were willing to learn from the aviation industry, I might feel as comfortable in the ER as I do flying on a 747.