Redefining Medicine With Apps and iPads - The Digital Doctor - NYTimes.com

<base href="data:"><nyt_text style="color: rgb(51, 51, 51); font-family: Georgia, serif; font-size: 13px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; "><div id="articleBody"><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">Dr. Alvin Rajkomar was doing rounds with his team at the University of California, San Francisco Medical Center when he came upon a puzzling case: a frail, elderly patient with a dangerously low sodium level.</p><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">As a third-year resident in internal medicine, Dr. Rajkomar was the senior member of the team, and the others looked to him for guidance. An infusion of saline was the answer, but the tricky part lay in the details. Concentration? Volume? Improper treatment could lead to brain <a href="http://health.nytimes.com/health/guides/symptoms/swelling/overview.html?inline=nyt-classifier" title="In-depth reference and news articles about Swelling." class="meta-classifier" style="color: rgb(102, 102, 153); text-decoration: none; ">swelling</a>, <a href="http://health.nytimes.com/health/guides/symptoms/seizures/overview.html?inline=nyt-classifier" title="In-depth reference and news articles about Seizures." class="meta-classifier" style="color: rgb(102, 102, 153); text-decoration: none; ">seizures</a> or even death.</p><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">Dr. Rajkomar had been on call for 24 hours and was exhausted, but the clinical uncertainty was "like a shot of adrenaline," he said. He reached into a deep pocket of his white coat and produced not a well-thumbed handbook but his <a href="http://topics.nytimes.com/top/reference/timestopics/subjects/i/iphone/index.html?inline=nyt-classifier" title="Recent and archival news about the iPhone." class="meta-classifier" style="color: rgb(102, 102, 153); text-decoration: none; ">iPhone</a>.</p><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">With a tap on an app called MedCalc, he had enough answers within a minute to start the saline at precisely the right rate.</p><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">The history of medicine is defined by advances born of bioscience. But never before has it been driven to this degree by digital technology.</p><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">The proliferation of gadgets, apps and Web-based information has given clinicians — especially young ones like Dr. Rajkomar, who is 28 — a black bag of new tools: new ways to diagnose symptoms and treat patients, to obtain and share information, to think about what it means to be both a doctor and a patient.</p><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">And it has created something of a generational divide. Older doctors admire, even envy, their young colleagues' ease with new technology. But they worry that the human connections that lie at the core of medical practice are at risk of being lost.</p><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">"Just adding an app won't necessarily make people better doctors or more caring clinicians," said Dr. Paul C. Tang, chief innovation and technology officer at Palo Alto Medical Foundation in Palo Alto, Calif. "What we need to learn is how to use technology to be better, more humane professionals."</p><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">Dr. Paul A. Heineken, 66, a primary care physician, is a revered figure at the <a title="Web site" href="http://www.sanfrancisco.va.gov/" style="color: rgb(102, 102, 153); text-decoration: none; ">San Francisco V.A. Medical Center</a>. He is part of a generation that shared longstanding assumptions about the way medicine is practiced: Physicians are the unambiguous source of medical knowledge; notes and orders are written in paper records while standing at the nurses' station; and X-rays are film placed on light boxes and viewed over a radiologist's shoulder.</p><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">One recent morning, while leading trainees through the hospital's wards, Dr. Heineken faced the delicate task of every teacher of medicine — using the gravely ill to impart knowledge.</p><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">The team arrived at the room of a 90-year-old World War II veteran who was dying — a ghost of a man, his face etched with pain, the veins in his neck protruding from the pressure of his failing heart.</p><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">Dr. Heineken apologized for the intrusion, and the patient forced a smile. The doctor knelt at the bedside to perform the time-honored tradition of percussing the heart. "Do it like this," he said, placing his left hand over the man's heart, and tapping its middle finger with the middle finger of his right.</p><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">One by one, each trainee took a turn. An <a href="http://health.nytimes.com/health/guides/test/x-ray-skeleton/overview.html?inline=nyt-classifier" title="In-depth reference and news articles about X-ray - skeleton." class="meta-classifier" style="color: rgb(102, 102, 153); text-decoration: none; ">X-ray</a> or echocardiogram would do the job more accurately. But Dr. Heineken wanted the students to experience discovering an enlarged heart in a physical exam.</p><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">Dr. Heineken fills his teaching days with similar lessons, which can mean struggling upstream against a current of technology. Through his career, he has seen the advent of CT scans, ultrasounds,<a href="http://health.nytimes.com/health/guides/test/mri/overview.html?inline=nyt-classifier" title="In-depth reference and news articles about MRI." class="meta-classifier" style="color: rgb(102, 102, 153); text-decoration: none; ">M.R.I.</a>'s and countless new lab tests. He has watched peers turn their backs on patients while struggling with a new computer system, or rush patients through their appointments while forgetting the most fundamental tools — their eyes and ears.</p><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">For these reasons, he makes a point of requiring something old-fashioned of his trainees.</p><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">"I tell them that their first reflex should be to look at the patient, not the computer," Dr. Heineken said. And he tells the team to return to each patient's bedside at day's end. "I say, 'Don't go to a computer; go back to the room, sit down and listen to them. And don't look like you're in a hurry.' "</p><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">One reason for this, Dr. Heineken said, is to adjust treatment recommendations based on the patient's own priorities. "Any difficult clinical decision is made easier after discussing it with the patient," he said.</p><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">It is not that he opposes digital technology; Dr. Heineken has been using the Department of Veterans Affairs' computerized patient record system since it was introduced 15 years ago. Still, his cellphone is an old flip model, and his experience with text messaging is limited.</p><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">His first appointment one recent day was with Eric Conrad, a 65-year-old Vietnam veteran with severe <a href="http://health.nytimes.com/health/guides/disease/emphysema/overview.html?inline=nyt-classifier" title="In-depth reference and news articles about Emphysema." class="meta-classifier" style="color: rgb(102, 102, 153); text-decoration: none; ">emphysema</a>. First came a conversation. Dr. Heineken had his patient sit on a chair next to his desk. Despondent, the patient looked down at his battered Reeboks, his breaths shallow and labored.</p><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">Dr. Heineken has been seeing Mr. Conrad since 1993, and since then, he said, "we've been fighting a saw-tooth battle with his weight."</p><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">In an instant, the computer generated a chart showing the jagged history of weight successfully gained, then lost. Dr. Heineken pivoted the computer screen so the patient could see a steady gain in recent months. "It's looking a lot better than it has," he said. Mr. Conrad's face brightened slightly.</p><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">Then Dr. Heineken turned his back to the computer and sat so close to the patient that they were knee to knee. Mr. Conrad drilled his gaze into his physician's eyes, looking for answers.</p><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">It was not until Dr. Heineken was ready to listen to Mr. Conrad's lungs that he asked him to move to the examining table.</p><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">"I love him to death," Mr. Conrad said about Dr. Heineken. "He's right to the point, good news or bad news."</p><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">Thirty-eight years and a technological revolution separate Dr. Heineken from Dr. Rajkomar.</p><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">The son of an electrical engineer from Mauritius, Alvin Rajkomar grew up in Silicon Valley and taught himself to program at age 12. As an undergraduate at Harvard, he started out in physics but became hooked on medicine in Mauritius, where he spent a few days one summer shadowing his uncle, a physician at a community clinic.</p><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">"There were no fancy medications or procedures," he said. "Just the art of doctoring."</p><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">In 2009, in his third year of medical school at Columbia, he was among the first in the hospital to use an iPhone as a clinical tool. "Every time you looked something up you'd get scolded," he said. "At that point, people believed that if you had your phone out you weren't working."</p><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">Among the new crop of device-happy physicians, Dr. Rajkomar is now an elder statesman of sorts, showing trainees his favorite apps, along with shortcuts through the electronic medical record and computerized prescribing system.</p><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">He stores every clinical nugget he finds on an application called Evernote, an electronic filing cabinet. "I use Evernote as a second brain," he said. "I now have a small textbook of personalized, auto-indexed clinical pearls that I carry with me at all times on my iPhone."</p><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">Along with MedCalc, the clinical calculator, Dr. Rajkomar's phone has ePocrates, an app for looking up drug dosages and interactions; and Qx Calculate, which he uses to create risk profiles for his patients. His favorite technology is his electronic stethoscope, which amplifies heart sounds while canceling out ambient noise.</p><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">Not that he is indiscriminate in his use of technology. When he decided the electronic health record was taking too long to load on his <a href="http://topics.nytimes.com/top/reference/timestopics/subjects/i/ipad/index.html?inline=nyt-classifier" title="More articles about iPad." class="meta-classifier" style="color: rgb(102, 102, 153); text-decoration: none; ">iPad</a>, he went back to taking notes by hand, on paper. But he is experimenting with writing by hand on a Samsung mini-tablet.</p><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">He is aware of the pitfalls of computerized records, particularly the "if the problem is X, then do Y" templates, which encourage a cut-and-paste approach to daily progress notes. While efficient, they can give rise to robotic bookkeeping without regard to how the patient is faring.</p><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">Tablet computers that are linked to electronic health records are making their way into the hands of medical trainees around the country. All internal-medicine residents at the University of Chicago and Johns Hopkins are given iPads; entering medical students at Stanford are given vouchers they can use to buy one.</p><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">A <a title="Abstract study" href="http://archinte.jamanetwork.com/article.aspx?articleid=1108771" style="color: rgb(102, 102, 153); text-decoration: none; ">University of Chicago study</a> this year in Archives of Internal Medicine found that residents with iPads were able to enter orders in a more timely manner, and a majority of residents perceived that the iPads improved their work efficiency. At the U.C.S.F. Medical Center, some physicians use iPads, and many use one of the hospital's computers on wheels.</p><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">Dr. Rajkomar's outpatient clinic is four miles west of the U.C.S.F. hospital, at the San Francisco V.A., where he works down the hall from Dr. Heineken.</p><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">Where Dr. Heineken is competent with the V.A.'s electronic health record system, Dr. Rajkomar is a virtuoso, a Vladimir Horowitz of the computer keyboard. He can keep his eyes fixed so steadily on the patient that the typing goes all but unnoticed.</p><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">As the conversation with the patient goes, so goes Dr. Rajkomar's interaction with the computer. Lab results? On the screen in a flash. A list of past and current medications and dosages? Voilà!</p><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">Yet he also knows when the computer needs to be set aside. During a visit, when a patient confided that his wife was taking his pain medication, Dr. Rajkomar excused himself and walked down the hall to consult with the pharmacist about a plan to keep that from happening.</p><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">Dr. Rajkomar knows he has a great deal to learn about being a physician, especially patients' social and psychological complexities.</p><p itemprop="articleBody" style="color: black; font-size: 1.2em; margin: 0px 0px 1em; line-height: 24px; ">"One patient fired me," he said, smiling as he added, "Dr. Heineken gets those patients."</p><nyt_correction_bottom><div class="articleCorrection" style="margin-bottom: 2.8em; "></div></nyt_correction_bottom><nyt_update_bottom></nyt_update_bottom></div></nyt_text><span style="color: rgb(51, 51, 51); font-family: Georgia, serif; font-size: 13px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; background-color: rgb(255, 255, 255); display: inline !important; float: none; "></span><div style="font-family: Helvetica; font-size: 14px; color: black; text-align: left; "><span class="Apple-style-span" style="font-size: medium; "><a href="http://www.nytimes.com/2012/10/09/science/redefining-medicine-with-apps-and-ipads-the-digital-doctor.html?">http://www.nytimes.com/2012/10/09/science/redefining-medicine-with-apps-and-ipads-the-digital-doctor.html?</a></span></div><div style="font-family: Helvetica; font-size: 14px; color: black; text-align: left; "><br class="webkit-block-placeholder"></div>

Redefining Medicine With Apps and iPads - The Digital Doctor - NYTimes.com

Dr. Alvin Rajkomar was doing rounds with his team at the University of California, San Francisco Medical Center when he came upon a puzzling...

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Enough for everyone's need but not everyone's greed

<blockquote class="tr_bq">"There's enough for everyone's need, not everyone's greed."<br />James Lee Adams, Sr., my grandfather</blockquote><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgasG-jGfsLOBcq6Bg8j-RxtFrHv3DOiUGLLrdM8vqzG0tZ0yhPEvk5imxwgMZ8RwI6P_SbK0gIu36mH2_XdGmb0hfm6nX0ZWX-DyXykRjI6-J7SMNkmbOGboX-3VONj7BoUfoGfd0ALiU1/s1600/bigstock-Large-And-Small-Goldfishes-Un-4084635.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="262" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgasG-jGfsLOBcq6Bg8j-RxtFrHv3DOiUGLLrdM8vqzG0tZ0yhPEvk5imxwgMZ8RwI6P_SbK0gIu36mH2_XdGmb0hfm6nX0ZWX-DyXykRjI6-J7SMNkmbOGboX-3VONj7BoUfoGfd0ALiU1/s400/bigstock-Large-And-Small-Goldfishes-Un-4084635.jpg" width="400" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Sometimes little fish need a chance.</td></tr></tbody></table><br />Greed is wanting more than you need.<br /><blockquote class="tr_bq">Websters says "<table class="ts" style="background-color: white; border-collapse: collapse; color: #222222; font-family: arial, sans-serif; font-size: small; line-height: 12.499999046325684px; text-align: left;"><tbody><tr><td style="padding: 0px;">Intense and selfish desire for something, esp. wealth, power, or food." </td></tr></tbody></table></blockquote>It is an insatiable desire to accumulate. I don't look down upon those who accumulate wealth and are successful. Greed is not synonymous with wealth, however. We see it in school.<br /><br />We should all be able to strive and succeed and benefit. The wealthy aren't necessarily greedy. There are those who are poor that can be greedy too.<br /><br />Someone poor could want to have what others have without working for it. Someone poor could be greedy to have the things that another earned. We can all be greedy for food or power.<br /><br /><h2>How does this relate to school?</h2><h3>Greed in the classroom.</h3><h4>Praise.</h4>I've seen some kids who are successful who cannot stand the idea of another child being recognized for anything. In fact, as I work to give honest praise, I might praise a child who doesn't usually get it and the child who gets a lot of praise will come to my desk later to point out something the other child did wrong. It is almost like the child who gets a lot of praise thinks there is a finite amount of praise. Greed for all the attention can cause fault finding and a desire to monopolize praise. Don't let it happen. This is often a problem for the academically successful. Don't let them be academically arrogant but inclusive of others, even those not as naturally gifted as themselves.<br /><br /><h4>Attention.</h4>Greed often happens with children who are ignored at home but misbehave in the classroom because it gives them the attention they crave. By monopolizing attention in the classroom, the student feels important. Being noticed in a bad way is better than being ignored to some students.<br /><br />Recognize this for what it is and intentionally give positive attention and notice when this is happening. If all of your time is being monopolized by one child, the child may have a need - yes, that is possible - but it is also possible that the child has a greed. A huge, insatiable desire for attention - whatever it takes. And it is often easier to get attention for bad behavior than good behavior.<br /><br /><h4>Conversation.</h4>Some students want to always be heard. The unwise teacher can think that because one or two students speak out and really get it, that everyone understands. This is a lie. Good teachers are good at bringing all students into the conversation. I set boundaries and have often used the poker chip example that I shared in <a href="http://coolcatteacher.blogspot.com/2012/10/10-ways-to-listen-more-talk-less-teach.html" target="_blank">10 Ways to Talk Less, Listen More, Teach Well.</a><br /><br /><h4>Food.</h4>Of course it can happen with food. There are hungry kids but there are also kids that want more than their fair share and will do whatever it takes to get the food of others.<br /><br /><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbD9_9Kr0RpRdmJyqzg1mcbqIJWrjNfmmLtY_rjMUi3X85-iQfMh96zq7j7t9XixCn_oWIYlsOxv3hWBqVAYmregDe2YwqEjvCQdh4R3xRZwykcdMYtHreE7PEuRf38zpx3LbKlVoDQyuv/s1600/bigstock-Cheering-Crowd-25662716.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbD9_9Kr0RpRdmJyqzg1mcbqIJWrjNfmmLtY_rjMUi3X85-iQfMh96zq7j7t9XixCn_oWIYlsOxv3hWBqVAYmregDe2YwqEjvCQdh4R3xRZwykcdMYtHreE7PEuRf38zpx3LbKlVoDQyuv/s320/bigstock-Cheering-Crowd-25662716.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Greed for all the attention and credit can kill a sense of team.</td></tr></tbody></table><br /><h3>Greed on the sports field.</h3>Greed can happen on the sports field too. It destroys teamwork when one athlete, gifted though he/ she be, tries to gain more glory without giving respect and honor to the teammates and coach. <br /><br />Greed can happen when those teammates are jealous of the superstar, even if that superstar is humble.<br /><br /><h3>Greedy teachers?</h3>Greed can happen when I want a moment of peace but a child has a problem and really needs me. There is, however, a need to have a break sometimes. There are teachers who will NEVER give time before school, after school, or during break. "I need my time," they'll say. Well, my job is to teach and help students and when they miss school, I do often have to tutor before and after school. That is the life of a teacher.<br /><br />Some teachers want all of the attention and it upsets these teachers when others get praise. We all crave attention and to know we matter but there is no excuse. Rejoice when others have good things happen.<br /><br />Some want to believe they have all the problems in the world. No one has a life as bad as they do. As soon as one person has a problem, they're unloading their Uzi-machine-gun clip of problems ready to fire to prove they have the worst life. No explanation for this, but I've seen it. I've probably done it a few times when I was having a pity party but it is a form of greed.<br /><br />Never saying no can be a form of greed. We want to do everything for everybody. WE all have one thing in common... 24 hours. That is all. No more, no less. Sometimes we must say no so we can be honest and balanced.<br /><h3>Greedy parents?</h3>There is a greed when wealthy parents of children, try to exert their monetary influence on the school to also get their children undeserved accolades, positions, or preference.<br /><br />This requires firm administrators with ethics to stand against this. Sometimes these parents may not know they are doing it, but are just more vocal than most.<br /><h2>Finding the balance.</h2>Teachers are constantly balancing between greed and need. We need to be wise and discerning as often, we are the ones who must find fairness amidst the complexity of human behavior. <br /><br />Administrators need this fairness and balance as well.<br /><br /><h3>There's enough for everyone's need but not everyone's greed. </h3>Greed is destructive if left unchecked. The greedy child may not realize it is happening or what he/she is doing. You can help these situations in positive, encouraging ways by pointing out the value of everyone.<br /><br />I like to teach about brainstorming and group dynamics and point out that often students who are quiet have great things to add. Great leaders bring out everyone and don't monopolize the conversation or the project. <br /><br />Greed takes many forms and it isn't just money. It can be attention, resources, praise. Scarcity can also cause greed - if people think that not much praise will be doled out -- they may fight for what little they think there will be.<br /><br />Why not create a situation where praise is lavish, but honest? A place where fairness resides. I know this sounds like heaven on earth, and that it may not be possible, however, as teachers and administrators, we must clearly be aware of the greed/need balance as we help meet the needs of everyone while combatting greed that breaks down teamwork and harms morale.<br /><br />Now, I need to get to school -- and that really is a need.<br /><br /><i><b>PS. This applies more than ever in the #edreform and #ebook movements as well as the desire to inundate students with advertising messages wherever they are.</b></i><br /><br /><br />- Written on my iPad using Blog Press by Vicki Davis, author, Flattening Classrooms, Engaging Minds<br /><br />Photo Credit: <a href="http://www.bigstock.com/" target="_blank">Big Stock</a>, you may not reuse photos unless you license them directly on their website or you are breaking copyright law.

Enough for everyone's need but not everyone's greed

"There's enough for everyone's need, not everyone's greed." James Lee Adams, Sr., my grandfather Sometimes little fish...

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gallery wall update courtesy of BirdAve

Hey all! The <a href="http://news-these-days.blogspot.com/2012/02/step-into-my-gallery.html" target="_blank">gallery wall</a> has gotten a spruce.<br /><br />I was lucky enough to win a print from <a href="http://www.birdave.com/" target="_blank">BirdAve Studio</a> via <a href="http://pawleysislandposh.blogspot.com/" target="_blank">Pawleys Island Posh</a> right before my vacation and I finally got around to hanging it up.<br /><br />It was hard to pick just one, and I'll definitely be getting more, but out of all the cities from all over the world I decided on Des Moines. Because of it's world class nightlife and excellent shopping of course. Actually it's where the hubs and I met (college) and it <i>is</i> a very happy place with very happy memories.<br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEipMNIZgd1WvviTvfrTgCo-NYjcDHru7djndp_UhvFmlYiyoQpNddHN-nbRetNXveyao1oXA-tNtrC9oNeS4MfVayuqYzNO03lxYRHQeeUFc0JKbfDM2Mfhxl42yFiTUyl9iyfl0F95FEcF/s1600/BirdAvePic2.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="640" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEipMNIZgd1WvviTvfrTgCo-NYjcDHru7djndp_UhvFmlYiyoQpNddHN-nbRetNXveyao1oXA-tNtrC9oNeS4MfVayuqYzNO03lxYRHQeeUFc0JKbfDM2Mfhxl42yFiTUyl9iyfl0F95FEcF/s640/BirdAvePic2.jpg" width="528" /></a></div><br /><div class="separator" style="clear: both; text-align: center;"></div>A great addition to the corner and one of the many perks of a gallery wall - the more the merrier. There is always room to add another special piece.<br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj8UmSjMcrxOM-wb_zmhXVElAnmQ0ezwMwYEaFzZdWXItcVQxX-cK0fLJWDqG6N3M4sUBMDdmSsiqwSeTh7pmlWfV9aklSqgUZ49ssnXseTPlfjt10dE28rFikdohYI6gEn26Hzu-1l0ITW/s1600/GalleryWallUpdate.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="640" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj8UmSjMcrxOM-wb_zmhXVElAnmQ0ezwMwYEaFzZdWXItcVQxX-cK0fLJWDqG6N3M4sUBMDdmSsiqwSeTh7pmlWfV9aklSqgUZ49ssnXseTPlfjt10dE28rFikdohYI6gEn26Hzu-1l0ITW/s640/GalleryWallUpdate.jpg" width="584" /></a></div><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhclx2dWdLwcwbZMH4UgTDCds-RXuiihcacIfbnHJpyxk7-L7sbuhzrmyQtwU39FAO9Jq_NJauGUY5ZivgHjB7HCZTLBQB0AqzVGHrLgmOYbMk8YzLg0QgiLE1euT9CLdzIcb-CzUjziQ4n/s1600/GalleryWallUpdate2.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="640" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhclx2dWdLwcwbZMH4UgTDCds-RXuiihcacIfbnHJpyxk7-L7sbuhzrmyQtwU39FAO9Jq_NJauGUY5ZivgHjB7HCZTLBQB0AqzVGHrLgmOYbMk8YzLg0QgiLE1euT9CLdzIcb-CzUjziQ4n/s640/GalleryWallUpdate2.jpg" width="640" /></a></div>So how about you? Did you get to gettin' on any projects this weekend? Did you see the RHONJ reunion?  There aren't words for those ladies.<br /><br />More spruces to come!

gallery wall update courtesy of BirdAve

Hey all! The gallery wall has gotten a spruce. I was lucky enough to win a print from  BirdAve Studio  via  Pawleys Island Posh  right befo...

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Daily Education and Technology News for Schools 10/09/2012

<ul class="diigo-linkroll"> <li> <p class="diigo-link"> <a href="http://www.gpb.org/the-ignite-show/season-1/episode/the-ignite-show-with-georgia-governor-nathan-deal">The Ignite Show with Georgia Governor Nathan Deal</a> </p> <p class="diigo-description">We recorded a show in Atlanta with Governor Nathan Deal about helping high school students choose their career track. We also discussed what flattening the classroom means and how one can integrate the world into your classroom to create rich learning experiences. Thank you to my friend Anne, the show's host, for inviting me on.</p> <p class="diigo-tags"> <span>tags:</span> <a href="http://www.diigo.com/user/coolcatteacher/education">education</a> <a href="http://www.diigo.com/user/coolcatteacher/news">news</a> <a href="http://www.diigo.com/user/coolcatteacher/flatclass">flatclass</a> <a href="http://www.diigo.com/user/coolcatteacher/edreform">edreform</a> <a href="http://www.diigo.com/user/coolcatteacher/careered">careered</a> <a href="http://www.diigo.com/user/coolcatteacher/career">career</a> <a href="http://www.diigo.com/user/coolcatteacher/tumblr">tumblr</a></p> </li> <li> <p class="diigo-link"> <a href="http://www.bamradionetwork.com/index.php?option=com_content&view=article&id=901:how-we-teacher-girls-to-have-unhealthy-self-image&catid=35:jackstreet54&Itemid=89">Teaching in the Age of Entitlement: How to Avoid Contributing to the Problem</a> </p> <p class="diigo-description">Some students believe they are entitled to grades just for showing up, according to new research, especially if they are paying for their education (like college or private school). On this Radio show at the BAM Radio Network hosted by RAE Pica, she talked with researchers, an anonymous teacher, and I had a small reflection from my own experience about entitlement. It was a fun show to record and is pretty short.</p> <p class="diigo-tags"> <span>tags:</span> <a href="http://www.diigo.com/user/coolcatteacher/education">education</a> <a href="http://www.diigo.com/user/coolcatteacher/news">news</a> <a href="http://www.diigo.com/user/coolcatteacher/edreform">edreform</a> <a href="http://www.diigo.com/user/coolcatteacher/entitlement">entitlement</a> <a href="http://www.diigo.com/user/coolcatteacher/tumblr">tumblr</a></p> </li> <li> <p class="diigo-link"> <a href="http://blog.lproof.org/2012/10/the-beauty-in-the-threadbare.html">The Beauty in the Threadbare « Living Proof Ministries Blog</a> </p> <p class="diigo-description">Beth Moore has been one of my longstanding mentors through her many Bible studies she has written, but this blog post will appeal to any of you... especially those who work too hard and too long (like me) - these words caught my attention: "Work martyrs are fake martyrs. They don’t count. They’re too self-important. It dawned on me about 2 years ago that no one was making me work nonstop but me so why, then, did I want to find somebody to blame for driving this skeleton like a shovel into quicksand? Anyway, I want to dance with my grandchildren at their weddings."  I want to dance with my grandchildren at their weddings too and my workload isn't doing that dream any favors. Rethinking many things in my life.</p> <p class="diigo-tags"> <span>tags:</span> <a href="http://www.diigo.com/user/coolcatteacher/education">education</a> <a href="http://www.diigo.com/user/coolcatteacher/news">news</a> <a href="http://www.diigo.com/user/coolcatteacher/workaholic">workaholic</a> <a href="http://www.diigo.com/user/coolcatteacher/work">work</a> <a href="http://www.diigo.com/user/coolcatteacher/tumblr">tumblr</a></p> </li> <li> <p class="diigo-link"> <a href="http://www.guardian.co.uk/education/2011/dec/23/primary-school-teachers-resign-facebook?CMP=twt_gu">Primary school teachers resign after Facebook insults about pupils | Education | The Guardian</a> </p> <p class="diigo-description">Facebook isn't private. Don't talk in bad ways about your children or students. You can't delete it. You can't erase it. If you're upset, pick up the phone, but even then, you could be recorded. Face to face, we'll you could be recorded too. I think you should be wary of venting but doing it in writing on a social network has to rank up there as the #1 dumb thing you can do. I see it on Tumblr all the time and it makes me cringe. Wake up. There is no private teacher's lounge online. Be wise and treat your students with respect. Sadly, the students can speak ill of their teachers all they want and no one deals with it, but we are adults and they are children. We are professionals and we should behave like it. Read this story and take heed. "Printouts of the Facebook comments were posted on fencing near the school. One said: "No wonder everyone is thick … inbreeding must damage brain development." Another referred to seeing pupils queuing in a discount store. The online exchange, allegedly between teachers at the school, prompted anger among parents."</p> <p class="diigo-tags"> <span>tags:</span> <a href="http://www.diigo.com/user/coolcatteacher/education">education</a> <a href="http://www.diigo.com/user/coolcatteacher/news">news</a> <a href="http://www.diigo.com/user/coolcatteacher/facebook">facebook</a></p> </li> </ul><p class="diigo-ps">Posted from <a href='http://www.diigo.com'>Diigo</a>. The rest of my favorite links are <a href='http://www.diigo.com/user/coolcatteacher'>here</a>.</p>

Daily Education and Technology News for Schools 10/09/2012

The Ignite Show with Georgia Governor Nathan Deal We recorded a show in Atlanta with Governor Nathan...

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We went to Tribeca.....again!!!

<span style="font-size: large;">If you are a regular reader of my blog you are probably getting a sense of what is my favourite restaurant in Ranelagh - it's Tribeca.  We are terrors for finding a restaurant we like and then continually going to it and never trying out any other place.</span><br /><span style="font-size: large;"><br /></span><span style="font-size: large;">On Sunday we met friends for lunch and when they asked us to make a booking you can imagine what restaurant we chose!!!</span><br /><span style="font-size: large;"><br /></span><span style="font-size: large;">The two friends were Frank & Eilish.  They brought their son with them and also Frank's sister and partner.  Frank loved the vibe of the restaurant, he was amazed by how busy it was and how there was such a good vibe in the place.  He had been speaking to the waiter about the steak special on the menu and he loved that when the waiter was delivering the steak to another table as he passed our table he nudged Frank and pointed out what the steak and eggs were like.  Frank turned to me and said "I got the nudge - I love that!!!"  </span><br /><span style="font-size: large;"><br /></span><span style="font-size: large;">Food came out and it was gorgeous as usual!  I also had a nice glass of house wine.  I ordered the merlot (as usual - as pointed out by Ciaran!).  After lunch we walked to our house and had coffee and cake for afters.  A lovely afternoon with friends!!</span><br /><span style="font-size: large;"><br /></span><span style="font-size: large;">Here's some <a href="http://massafelliphotography.com/tribeca-restaurant-at-ranelagh/">photo's of Tribeca </a>that I found on the Internet as well as a <a href="http://ramp.ie/index.php/Go_Fork_Yourself-detail/fork-yourself-tribeca-ranelagh/">review</a> of the restaurant.</span>

We went to Tribeca.....again!!!

If you are a regular reader of my blog you are probably getting a sense of what is my favourite restaurant in Ranelagh - it's Tribeca.  ...

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An Open Letter to Alan Levy CEO of Blog Talk Radio

<div dir="ltr" style="text-align: left;" trbidi="on">Sometimes I find that being an internationally renown internet radio celebrity type can lead to frustration.<br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiJ7xqv1ux6FV3ZxYrb9LOxuxMRV0N2x0NWs1OzCbNdiYk58JLYBZOb6avMDChyphenhyphenxKjT6y5BICpNIJJEmDC3vDop9-6srCSZ1sFMsHzAqwP2VdjpurEhZduOrmB7C4qfBJwanH6BeZkKSKA/s1600/Alan+Levy+Blog+Talk+Radio.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiJ7xqv1ux6FV3ZxYrb9LOxuxMRV0N2x0NWs1OzCbNdiYk58JLYBZOb6avMDChyphenhyphenxKjT6y5BICpNIJJEmDC3vDop9-6srCSZ1sFMsHzAqwP2VdjpurEhZduOrmB7C4qfBJwanH6BeZkKSKA/s400/Alan+Levy+Blog+Talk+Radio.jpg" width="400" /></a></div>Oh sure…The notoriety is non-stop. Fame follows me. And the chicks?<br /><br />Holy Cow, if either Jayman or I fail to get hit on or propositioned by less than eight uber-hot babes in a single day, we consider that day to be sub par, and well, an aberration.<br /><br />Anyhoo…<br /><br />I have no problem helping to write and produce the show.  I have no problem being my witty self on air.  I have no problem with helping Jayman to provide laughter and entertainment to millions across this Big Blue Marble of ours.<br /><br />But ya know what I DO have a problem with?<br /><br />The forum which we utilize to entertain and inform both the washed and unwashed masses, Blog Talk Radio!!<br /><br />Damn right.<br /><br />I know, I know….It is a free service and Jay and I don’t pay the Premium Membership in order to get all the bells and whistles, but man…I just don’t understand some things about BTR, so I have a few questions for its Co-Founder and CEO, one Alan Levy.<br /><br />For instance…Our <i>“A Couple of Sickos”</i> show from September 30th…It had been Number One in the Comedy category for days and yesterday?  It was still getting hundreds of listens, and yet?<br /><br />Poof!!  It disappeared from the ratings altogether.  WTF?  How does that happen?<br /><br />Gee Mr. Levy, I’m sorry that all those crappy shows that pay you $399.00 or more a year can’t compete with <i>IWS Radio</i>, but that’s no reason to callously and arbitrarily erase our greatness from every book, ledger, and internet obelisk!!<br /><br />We go through this every week.  <i>IWS Radio</i> is on the top of the ratings and then BAM!!  You sprinkle your Emeril dust on us and we are served up to be the main course upon the dinner table of obscurity.<br /><br />You know the truth Mr. Alan Levy…With our numbers, <i>IWS Radio </i>would show up on the comedy category ratings as shows Number one through ten!!  Uh-huh…but noooo…<br /><br />You there at BTR have some Masonic type rating system that us non-Knight Templar radio types know nothing about.  I bet you and your staff laugh at Jay and I as you do your secret BTR handshake and pull us from our Number One spot every week.<br /><br />Hell, you won’t even let us be Number One in different categories at the same time.  What’s up with that?  I am so sorry that we are that awesome, but evidently you look down upon awesomeness and in turn choose to reward mediocrity.  Such a rare and odd trait in a successful CEO and business type guy.<br /><br />Another thing…I have a problem with your $399.00 Premium Member charge. Without it, BTR limits Jay and I to 45 minutes per show, offers us no promos, and yet, we still hit Number One every week, and you know what?<br /><br />As of late, our two shows per week are getting a total of 5,000-7,000 listens per week.  So let’s be temperate and call it 6,000 per week.<br /><br />People who listen to our show see one helluva lot of ads that you load onto our show page, and let’s say your ad revenue is equal to one cent per listen on our show.<br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhNoilUFNHGv2CormP31A8rchQ_DnveDAezqeH2M3CTL9mmjkMhzSFtSJ34nIiUvxTwUw7a97fjIZJreTQ7qHVREgkbqYoVWoGh35Rby9wXvwLslBV8ODsnR2jMNAhIH4Wr3TotXauD6V0/s1600/Alan+Levy+CEO+Blog+Talk+Radio.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhNoilUFNHGv2CormP31A8rchQ_DnveDAezqeH2M3CTL9mmjkMhzSFtSJ34nIiUvxTwUw7a97fjIZJreTQ7qHVREgkbqYoVWoGh35Rby9wXvwLslBV8ODsnR2jMNAhIH4Wr3TotXauD6V0/s400/Alan+Levy+CEO+Blog+Talk+Radio.jpg" width="400" /></a></div>You are making at least $60.00 per week off of our unbridled talent, and what do we get for our efforts? That’s right…Heartache!!<br /><br />You are easily and conservatively estimating, making over $3,000.00 a year on our show and you can’t say unto us…<i><br /></i><br /><i>“I’m sorry, that I can’t change the way we rate shows, because honestly, I don’t even know how that works, but since you are such a consistently great radio show and make money for us, I will pay your $399.00 in order to become a Premium Member, and therefore you can do longer shows and generate even more income for me.”</i><br /><br />See Mr. Alan Levy how easy that would be?  You owe us mister…You owe us big time, and you need to do the right thing and pay our Premium Membership.  You owe it to us, but more importantly…<br /><br />You owe it to the world and our adoring, ad-clicking fans.<br /><br /><i>Cheers!!</i><br />Matt-Man<br /><i><span style="color: blue;"><a href="mailto:mattmaniws@ymail.com">mattmaniws@ymail.com</a></span></i><br /><a href="https://twitter.com/MattMan_IWS"><i><span style="color: blue;">@MattMan_IWS</span></i></a></div>

An Open Letter to Alan Levy CEO of Blog Talk Radio

Sometimes I find that being an internationally renown internet radio celebrity type can lead to frustration. Oh sure…The notoriety is non-st...

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Monday, Monday

<span style="font-weight: bold;"><a href="http://www.archidose.org/wp/">A Weekly Dose of Architecture</a> Updates:</span><br /><br />This week's dose features <a href="http://archidose.org/wp/2012/10/08/brooklyn-army-terminal/">Brooklyn Army Terminal</a> in Brooklyn, New York by Cass Gilbert:<br /><a href="http://archidose.org/wp/2012/10/08/brooklyn-army-terminal/"><img alt="this week's dose" src="http://archidose.org/wp/wp-content/uploads/2012/10/Oct12-08.jpg" style="cursor: move;" title="This week's dose" width="640" /></a><br /><br />The featured past dose is the <a href="http://archidose.org/wp/2004/11/15/cognito-films/">Cognito Films</a> in Culver City, California by Randall Stout Architects:<br /><a href="http://archidose.org/wp/2004/11/15/cognito-films/"><img alt="this week's dose" src="http://www.archidose.org/Nov04/cognito1.jpg" style="cursor: move;" title="featured past dose" width="640" /></a><br /><br />This week's book review is <a href="http://archidose.org/wp/2012/10/08/toyo-ito-forces-of-nature/"><i>Toyo Ito: Forces of Nature</i></a> edited by Jessie Turnbull (L):<br /><a href="http://archidose.org/wp/2012/10/08/toyo-ito-forces-of-nature/"><img alt="this week's book review" height="300" src="http://archidose.org/wp/wp-content/uploads/2012/10/ito.jpg" style="cursor: move;" title="This week's book review" /></a>   <a href="http://www.archidose.org/books/ando.html"><img alt="this week's book review" height="300" src="http://www.archidose.org/books/ando.jpg" style="cursor: move;" title="This week's book review" /></a><br />(R): The featured past book review is <a href="http://www.archidose.org/books/ando.html"><i> Seven Interviews with Tadao Ando</i></a> by Michael Auping.

Monday, Monday

A Weekly Dose of Architecture Updates: This week's dose features Brooklyn Army Terminal in Brooklyn, New York by Cass Gilbert: The fea...

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Some 13,000 May Have Gotten Meningitis-Linked Drug - WSJ.com

An estimated 13,000 patients may have been exposed to the tainted spinal steroid injections which have sickened more than 100 people with fungal meningitis and killed eight, federal officials said Monday, as clinics and surgery centers continued to reach out to those who could be affected.<br /><br><br /><br>It was the first estimate of the potential scope of the meningitis outbreak, which has been traced by federal and state investigators to three lots of methylprednisolone acetate injections produced by New England Compounding Center. Some 105 people in nine states have been sickened by fungal meningitis, said Curtis Allen, a spokesman for the Centers for Disease Control and Prevention.<br /><br><br /><br>Tennessee, Virginia, Indiana, Maryland and Michigan reported new cases. Tennessee—with 35 cases, the most of any state—also reported an additional death, its fourth, according to the CDC.<br /><br><br /><br>Investigators from the U.S. Food and Drug Administration and state officials are probing the Framingham, Mass., facility where NECC made the 17,676 potentially tainted steroid injections, which were then shipped to 75 clinics in 23 states, according to federal and state officials.<br /><br><br /><br>A CDC spokesman said it isn't possible to know how many cases there will be. The CDC and state health officials scrambled last week and over the weekend to track down patients who received the shots to see if they had been sick and to warn them to watch for possible symptoms.<br /><br><br /><br>The numbers of cases are rising sharply now not necessarily because people are continuing to get sick, but because investigators are pinpointing more illnesses among those who already received the injections of methylprednisolone acetate for relief of back and neck pain.<br /><br><br /><br>The injections were given between July and September. So far, those who have been infected developed symptoms between one and four weeks after receiving their injections.<br /><br><br /><br>"There's no evidence that new infections are occurring at a more rapid rate," said John Jernigan, medical epidemiologist at the CDC who is involved in the investigation.<br /><br><br /><br>It is too early to know how many people ultimately will be affected. Federal and state investigators must determine how many people received potentially contaminated injections, then track down each one. They must then confirm that those who have subsequently become ill actually had fungal meningitis and not another disease. There are "too many variables to speculate on the number of possible cases," said a CDC spokesman.<br /><br><br /><br>The FDA had already advised medical professionals last week not to use NECC-made products.The compounding pharmacy that produced the injections in question issued a recall Saturday of all products made at its compounding center. "This action is being taken out of an abundance of caution due to the potential risk of contamination," NECC said in a statement. The company has said it is cooperating with investigators.<br /><br><br /><br>Meningitis is a potentially deadly inflammation of the brain or central nervous system. It is usually caused by viruses or bacteria, but can also be brought on by fungi. The two fungi found thus far in some patients—known as aspergillus and exserohilum—are commonly found in the air and soil.<br /><br><br /><br>The fungal form of meningitis is particularly difficult to diagnose because the symptoms can be vague and mild initially, including fever, headache, nausea and stiffness of the neck, according to the CDC. People with fungal meningitis can also experience dizziness and confusion. Several of the patients in the current outbreak have had strokes.<br /><br><br /><br>Most of the people who have been sickened had normal immune systems, Dr. Jernigan said, meaning they weren't at particular risk of infections. While the investigation into how patients became infected is ongoing, there is some evidence to suggest that the fungi in the medication penetrated the lining protecting the central nervous system after being injected epidurally, Dr. Jernigan said.<br /><br><br /><br>While the fungi aren't harmful in the environment, they can become deadly when they flourish in a medication and are then injected directly into a part of the body that should not have germs, Dr. Jernigan said.<br /><br><br /><br>Ms. Reed underwent an autopsy; the lawyer said he didn't yet know the results.One possible victim, 56-year-old Tennessee resident Diana Reed, died Wednesday; she got meningitis after receiving steroid injections, says a lawyer for her family. She had received the injections at a facility that has since been closed because of a meningitis outbreak, according to its Web site.<br /><br><br /><br>The outbreak has drawn renewed attention to the little-regulated world of compounding pharmacies. The FDA is hampered by federal law and conflicting federal court decisions over its authority to regulate compounding pharmacies. Current and former senior FDA officials said the agency has sought greater authority over the past decade, but so far has been stymied.<br /><br><br /><br>Government officials say the FDA is especially concerned about large compounding pharmacies that send out large amounts of drugs across the country—as opposed to a small pharmacy that may compound a medication three or four times a year.<br /><br><br /><br>In particular, the agency hasn't been able to take the normal steps it would take to ensure the safety of a drug produced at a compounding pharmacy. That includes requiring and evaluating clinical trials, and inspection of manufacturing facilities.<br /><br><br /><br>Attempts in the past by the agency to regulate more strenuously have been challenged in court.<br /><br><br /><br><a href="http://online.wsj.com/article/SB10000872396390443982904578044682649925200.html">http://online.wsj.com/article/SB10000872396390443982904578044682649925200.html</a>?

Some 13,000 May Have Gotten Meningitis-Linked Drug - WSJ.com

An estimated 13,000 patients may have been exposed to the tainted spinal steroid injections which have sickened more than 100 people with fu...

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Tackling the Underlying Problems of Failure to Rescue :: Article - The Hospitalist

<base href="data:"><div style="font-family: Helvetica; font-size: 14px; color: black; text-align: left; "><p style="margin: 0px 0px 1em; padding: 0px; font-size: 1.2em; line-height: 1.5em; color: rgb(0, 0, 0); font-family: Georgia, 'Times New Roman', Times, serif; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">A recent HealthGrades Quality Study titled <em style="margin: 0px; padding: 0px; ">Patient Safety in American Hospitals</em> (July 2004) highlighted the frequency of patients dying from complications that develop while in hospitals. Failure to rescue, according to the 3-year study, accounts for 60,000 deaths each year in Medicare patients under the age of 75.</p><p style="margin: 0px 0px 1em; padding: 0px; font-size: 1.2em; line-height: 1.5em; color: rgb(0, 0, 0); font-family: Georgia, 'Times New Roman', Times, serif; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">Based on my experience as a pulmonary and critical care physician, this statistic quantifies an important problem. Deaths from complications of illness, or care, during a hospital stay happen more than we'd like to admit. However, the good news is that by identifying the underlying problem and deploying some targeted, systemic changes, hospitalists can begin to handle decompensation quickly, proactively, and before it's too late.</p><p style="margin: 0px 0px 1em; padding: 0px; font-size: 1.2em; line-height: 1.5em; color: rgb(0, 0, 0); font-family: Georgia, 'Times New Roman', Times, serif; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">Moving forward, hospitals need to build an effective patient safety net, which requires three important elements: point-of care tools for caregivers, proactive clinical surveillance, and real-time process monitoring.</p><div class="imageContainer" style="margin: 10px 0px 10px 10px; padding: 0px; width: 295px; float: right; color: rgb(0, 0, 0); font-family: Georgia, 'Times New Roman', Times, serif; font-size: 10px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: 15px; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; "><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgUjhmmQ1UV0h-VQrvWuDweiqmlekDkIe7DAifMgMKuzZmFsyJRuMKP945lC5T4HdjfXJyWl2uHUaXoqd7XxnKXn5VkPPf9VeTBcmXKdcoFVC9H11mhnYmVr5sxqOv7KIWZhMZaSMLSED8/s1600/2005_02_pp34_01-700543.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5796938836374589618" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgUjhmmQ1UV0h-VQrvWuDweiqmlekDkIe7DAifMgMKuzZmFsyJRuMKP945lC5T4HdjfXJyWl2uHUaXoqd7XxnKXn5VkPPf9VeTBcmXKdcoFVC9H11mhnYmVr5sxqOv7KIWZhMZaSMLSED8/s320/2005_02_pp34_01-700543.jpg" /></a><div class="imageCaption" style="margin: 0px; padding: 10px 0px 0px; font-family: Trebuchet, 'Trebuchet MS', Helvetica, sans-serif; font-size: 14px; border-top-width: thin; border-top-style: solid; border-top-color: rgb(204, 204, 204); color: rgb(51, 51, 51); ">FIGURE 1. Catastrophe Timeline — Review of the patient's chart revealed instability had been developing for hours before a "code" was called</div></div><h3 style="margin: 0px 0px 0.3em; padding: 0px; font-size: 1.25em; color: rgb(0, 0, 0); font-family: Georgia, 'Times New Roman', Times, serif; font-style: normal; font-variant: normal; letter-spacing: normal; line-height: 15px; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">Reasons for Failure to Rescue</h3><p style="margin: 0px 0px 1em; padding: 0px; font-size: 1.2em; line-height: 1.5em; color: rgb(0, 0, 0); font-family: Georgia, 'Times New Roman', Times, serif; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">A huge effort, and amount of money, has been focused on finding errors that lead to harm. Unfortunately, we're tackling the wrong errors. New tools like barcode medication administration or CPOE tackle errors of commission. These errors might occur when a doctor or nurse administers a wrong dose or wrong medication. Errors of commission are much easier to identify and solve, but clinically significant errors of commission that cause harm are relatively rare events and don't affect overall hospital mortality.</p><p style="margin: 0px 0px 1em; padding: 0px; font-size: 1.2em; line-height: 1.5em; color: rgb(0, 0, 0); font-family: Georgia, 'Times New Roman', Times, serif; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">Errors of <em style="margin: 0px; padding: 0px; ">omission</em>, however, are much more insidious. An error of omission is an error that occurs when an action is not taken or an important step in the process is left out. Examples of an error of omission include sub-optimal patient care resulting from the inadequate availability of patient information for decision-making, or a more blatant example, when a patient's vital signs indicate decompensation but the clinical response is inadequate or delayed.</p><p style="margin: 0px 0px 1em; padding: 0px; font-size: 1.2em; line-height: 1.5em; color: rgb(0, 0, 0); font-family: Georgia, 'Times New Roman', Times, serif; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">Errors of omission continue in today's hospitals for two very important reasons: First, we lack a systematic way to handle clinical decompensation. While we have "code" teams, their efforts often come into play too late. Second, lacking a way to recognize and respond to the issue, we have accepted that failure to rescue is in some ways inevitable and excusable.</p><p style="margin: 0px 0px 1em; padding: 0px; font-size: 1.2em; line-height: 1.5em; color: rgb(0, 0, 0); font-family: Georgia, 'Times New Roman', Times, serif; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">The basic, first step is to replace the inherently unreliable paper patient chart. Paper patient charts get misplaced, information is sometimes missing and/or illegible, and they make it impossible for a team effort to optimize care.</p><p style="margin: 0px 0px 1em; padding: 0px; font-size: 1.2em; line-height: 1.5em; color: rgb(0, 0, 0); font-family: Georgia, 'Times New Roman', Times, serif; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">Hospitals need to get patient data such as vital signs and medication usage in electronic form. That way, it is effortless and time-efficient to determine a patient's status and check up on patients even when not physically near them. Making this change alone, even in only one hospital unit, hospitalists can begin to effect significant positive changes in patient safety outcomes.</p><h3 style="margin: 0px 0px 0.3em; padding: 0px; font-size: 1.25em; color: rgb(0, 0, 0); font-family: Georgia, 'Times New Roman', Times, serif; font-style: normal; font-variant: normal; letter-spacing: normal; line-height: 15px; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">Catastrophes Aren't Inevitable</h3><p style="margin: 0px 0px 1em; padding: 0px; font-size: 1.2em; line-height: 1.5em; color: rgb(0, 0, 0); font-family: Georgia, 'Times New Roman', Times, serif; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">Often, the first time physicians become aware of a problem is when they receive a frantic call to come to the bedside. The patient is decompensating and needs immediate, dramatic intervention to save their life. However, when we take the time to look back at the patient chart and "connect the dots," we see that instability had been developing for hours before an urgent summons for assistance.</p><p style="margin: 0px 0px 1em; padding: 0px; font-size: 1.2em; line-height: 1.5em; color: rgb(0, 0, 0); font-family: Georgia, 'Times New Roman', Times, serif; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">Even with the best care, patients' clinical needs often change after admission. Patient status can change rapidly, so a perfect assessment earlier in the day can quickly become dated. Further, bedside staff have many other patients, and staffing assignments don't build in "slack time" to permit paying extra attention when problems develop. Consequently, signs of clinical deterioration are often missed or not acted upon until there's a code on the unit and dramatic measures are needed to save a life.</p><p style="margin: 0px 0px 1em; padding: 0px; font-size: 1.2em; line-height: 1.5em; color: rgb(0, 0, 0); font-family: Georgia, 'Times New Roman', Times, serif; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">Proactive clinical surveillance tools are the second big step in creating a safety net for patients. With patient data in electronic form, hands-on caregivers, nurses, and supervisors can use specially designed "dashboard views" to quickly identify which patients are exhibiting warning signs of clinical decline and exactly where they are located.</p><p style="margin: 0px 0px 1em; padding: 0px; font-size: 1.2em; line-height: 1.5em; color: rgb(0, 0, 0); font-family: Georgia, 'Times New Roman', Times, serif; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">To be most effective, staff should view clinical surveillance information in a variety of useful ways:</p><ul style="margin: 1em 0px 1em 2em; padding: 0px; color: rgb(0, 0, 0); font-family: Georgia, 'Times New Roman', Times, serif; font-size: 10px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: 15px; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; "><li style="margin: 0px; padding: 0px; font-size: 1.2em; line-height: 1.5em; ">Hospital–wide for a big picture of where the trouble spots are</li><li style="margin: 0px; padding: 0px; font-size: 1.2em; line-height: 1.5em; ">By unit, to scan through patients and see the values that are triggering an alert</li><li style="margin: 0px; padding: 0px; font-size: 1.2em; line-height: 1.5em; ">By provider, so doctors and nurses can scan their list of patients and see which have triggered alerts</li><li style="margin: 0px; padding: 0px; font-size: 1.2em; line-height: 1.5em; ">By patient, drilling into all the details of that patient's current status and previous care</li><li style="margin: 0px; padding: 0px; font-size: 1.2em; line-height: 1.5em; ">By patient, drilling into all the details of that patient's current status and previous care</li></ul><p style="margin: 0px 0px 1em; padding: 0px; font-size: 1.2em; line-height: 1.5em; color: rgb(0, 0, 0); font-family: Georgia, 'Times New Roman', Times, serif; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">tion, which are out of range or trending in the wrong direction, should automatically highlight patients. With the complete clinical record on-line, staff can prioritize which patients to visit next and what type of supplemental resources might be needed to enhance care.</p><p style="margin: 0px 0px 1em; padding: 0px; font-size: 1.2em; line-height: 1.5em; color: rgb(0, 0, 0); font-family: Georgia, 'Times New Roman', Times, serif; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">For hospitalists, clinical surveillance tools save an immense amount of time and help prioritize patient care. Typically hospitalists manage a large number of patients who are scattered around the hospital. Determining where to start rounds and which patients should be seen first is often difficult. Even worse, patients' conditions suddenly change for the worse soon after you've checked on them. There are just too many patients to continually be looking at patient charts and relying on verbal information: that's why there are computers!</p><p style="margin: 0px 0px 1em; padding: 0px; font-size: 1.2em; line-height: 1.5em; color: rgb(0, 0, 0); font-family: Georgia, 'Times New Roman', Times, serif; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">Supervisory staff can provide an additional safety net, if they have the tools to do so effectively. Typically, they rely on "report" and walking around, visiting staff, looking for an opportunity where their intervention could be helpful. By referring to "hot spots" indicated on a clinical surveillance dashboard view, they would know where they're needed and spend their time helping, rather than prospecting.</p><p style="margin: 0px 0px 1em; padding: 0px; font-size: 1.2em; line-height: 1.5em; color: rgb(0, 0, 0); font-family: Georgia, 'Times New Roman', Times, serif; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">Some hospitals have formalized their response to the failure to rescue problem by creating "rapid response teams." Such teams can also rely on clinical surveillance tools to identify patients in need, rather than waiting for a phone call from an overwhelmed primary caregiver.</p><div class="imageContainer" style="margin: 10px 0px 10px 10px; padding: 0px; width: 295px; float: right; color: rgb(0, 0, 0); font-family: Georgia, 'Times New Roman', Times, serif; font-size: 10px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: 15px; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; "><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj2x-k8t0VbVzJuQhOiapQdkh9-nnbXRN3T-Amca9yTLbUBD39L34XbgGE-mj_JwpXPEZGCaBTd8CgGdnha1MX5KV0i2hcb-rHd2cAX0Vs3xK-HA5MDbqjWvty9KVykiFx0G441KUJdiXM/s1600/2005_02_pp35_01-703468.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5796938847364258946" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj2x-k8t0VbVzJuQhOiapQdkh9-nnbXRN3T-Amca9yTLbUBD39L34XbgGE-mj_JwpXPEZGCaBTd8CgGdnha1MX5KV0i2hcb-rHd2cAX0Vs3xK-HA5MDbqjWvty9KVykiFx0G441KUJdiXM/s320/2005_02_pp35_01-703468.jpg" /></a><div class="imageCaption" style="margin: 0px; padding: 10px 0px 0px; font-family: Trebuchet, 'Trebuchet MS', Helvetica, sans-serif; font-size: 14px; border-top-width: thin; border-top-style: solid; border-top-color: rgb(204, 204, 204); color: rgb(51, 51, 51); ">FIGURE 2. Clinical surveillance information may be seen in "dashboard views" by unit or provider, to scan through patients and see values that triggered an alert.</div></div><h3 style="margin: 0px 0px 0.3em; padding: 0px; font-size: 1.25em; color: rgb(0, 0, 0); font-family: Georgia, 'Times New Roman', Times, serif; font-style: normal; font-variant: normal; letter-spacing: normal; line-height: 15px; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">Making Best Practices Work</h3><p style="margin: 0px 0px 1em; padding: 0px; font-size: 1.2em; line-height: 1.5em; color: rgb(0, 0, 0); font-family: Georgia, 'Times New Roman', Times, serif; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">Organizational performance can be dramatically improved when patient outcomes and staff activity can be measured and analyzed. Traditionally, this has been done retrospectively.</p><p style="margin: 0px 0px 1em; padding: 0px; font-size: 1.2em; line-height: 1.5em; color: rgb(0, 0, 0); font-family: Georgia, 'Times New Roman', Times, serif; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">By evaluating outcomes of patients and compliance with processes, many sites have been able to improve processes for future patients. However, because reporting has been periodic, results become available only months later, and implementation of care enhancements are delayed.</p><p style="margin: 0px 0px 1em; padding: 0px; font-size: 1.2em; line-height: 1.5em; color: rgb(0, 0, 0); font-family: Georgia, 'Times New Roman', Times, serif; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">With comprehensive patient data in electronic form, real-time monitoring of compliance with intended processes and best practices becomes possible. For example, if there is a consensus that the head of the bed of ventilated patients should be elevated to reduce the incidence of ventilator-associated pneumonia, then the monitoring system can show, by ICU, the percentage compliance with that protocol at any given moment.</p><p style="margin: 0px 0px 1em; padding: 0px; font-size: 1.2em; line-height: 1.5em; color: rgb(0, 0, 0); font-family: Georgia, 'Times New Roman', Times, serif; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">Since the report is available real-time, non-compliance can be addressed immediately, benefiting the patient and directing education about the protocol precisely when and where it is needed for maximum impact.</p><h3 style="margin: 0px 0px 0.3em; padding: 0px; font-size: 1.25em; color: rgb(0, 0, 0); font-family: Georgia, 'Times New Roman', Times, serif; font-style: normal; font-variant: normal; letter-spacing: normal; line-height: 15px; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">Creating a Reliable Patient Safety System</h3><p style="margin: 0px 0px 1em; padding: 0px; font-size: 1.2em; line-height: 1.5em; color: rgb(0, 0, 0); font-family: Georgia, 'Times New Roman', Times, serif; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">An electronic medical record forms the very foundation of a patient safety system. This electronic data provides the capability for proactive clinical monitoring and much more sophisticated process analysis that happens in days or weeks, not over a course of months or years.</p><p style="margin: 0px 0px 1em; padding: 0px; font-size: 1.2em; line-height: 1.5em; color: rgb(0, 0, 0); font-family: Georgia, 'Times New Roman', Times, serif; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">Capture patient data electronically, set up a set of effective alerts based on hospital-defined triggers, and enact process monitoring to improve outcomes and fix problems as they occur. With these three elements, hospitals have the best antidote for failure to rescue and are able to create a safety net for patients.</p></div><a href="http://www.the-hospitalist.org/details/article/257883/Tackling_the_Underlying_Problems_of_Failure_to_Rescue.html">http://www.the-hospitalist.org/details/article/257883/Tackling_the_Underlying_Problems_of_Failure_to_Rescue.html</a><div style="font-family: Helvetica; font-size: 14px; color: black; text-align: left; "><br class="webkit-block-placeholder"></div>

Tackling the Underlying Problems of Failure to Rescue :: Article - The Hospitalist

A recent HealthGrades Quality Study titled  Patient Safety in American Hospitals  (July 2004) highlighted the frequency of patients dying fr...

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Can failure to rescue be a key indicator of patient safety? | Practice | Nursing Times

<base href="data:"><div style="font-family: Helvetica; font-size: 14px; color: black; text-align: left; "><div class="standfirst" style="font-weight: bold; color: rgb(51, 51, 51); font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 13px; font-style: normal; font-variant: normal; letter-spacing: normal; line-height: 18px; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; background-color: rgb(255, 255, 255); "><p style="margin: 0px 0px 10px; font-size: 0.923em; ">A look at whether administrative data in English hospitals contain enough information to reliably report "failure to rescue" rates and to what extent they affect patient safety</p></div><div style="margin-top: 0px; margin-right: 0px; margin-bottom: 10px; margin-left: 0px; font-size: 0.923em; color: rgb(51, 51, 51); font-family: Verdana, Arial, Helvetica, sans-serif; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: 18px; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; background-color: rgb(255, 255, 255); position: static; z-index: auto; "><br class="webkit-block-placeholder"></div><div class="factfile" style="background-color: rgb(229, 229, 229); padding: 0px 0px 8px; clear: both; color: rgb(51, 51, 51); font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 13px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: 18px; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; "><h2 style="font-weight: bold; font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 0.923em; line-height: 18px; margin: 0px 0px 6px; color: rgb(255, 255, 255); background-image: none; display: block; text-transform: uppercase; padding: 0px 4px; position: relative; background-color: rgb(0, 84, 159); ">IN THIS ARTICLE…</h2><ul style="margin: 0px 8px 11px; padding-left: 0px; list-style: none; overflow: hidden; "><li style="background-image: url(http://www.nursingtimes.net/magazine/graphics/breadcrumb-bg.gif); padding: 0px 0px 0px 9px; margin: 0px; display: block; background-position: 0px 7px; background-repeat: no-repeat no-repeat; ">What "failure to rescue" (FTR) does and does not indicate</li><li style="background-image: url(http://www.nursingtimes.net/magazine/graphics/breadcrumb-bg.gif); padding: 0px 0px 0px 9px; margin: 0px; display: block; background-position: 0px 7px; background-repeat: no-repeat no-repeat; ">How to judge whether FTR measurements are reliable</li><li style="background-image: url(http://www.nursingtimes.net/magazine/graphics/breadcrumb-bg.gif); padding-top: 0px; padding-right: 0px; padding-bottom: 0px; padding-left: 9px; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; display: block; position: static; z-index: auto; background-position: 0px 7px; background-repeat: no-repeat no-repeat; ">Whether FTR rates can be derived from English hospital data</li></ul></div><div class="factfile" style="background-color: rgb(229, 229, 229); padding-top: 0px; padding-right: 0px; padding-bottom: 8px; padding-left: 0px; clear: both; color: rgb(51, 51, 51); font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 13px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: 18px; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; position: static; z-index: auto; "><h2 style="font-weight: bold; font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 0.923em; line-height: 18px; margin-top: 0px; margin-right: 0px; margin-bottom: 6px; margin-left: 0px; color: rgb(255, 255, 255); background-image: none; display: block; text-transform: uppercase; padding-top: 0px; padding-right: 4px; padding-bottom: 0px; padding-left: 4px; position: relative; background-color: rgb(0, 84, 159); z-index: auto; ">KEY POINTS FOR POLICY</h2><ol style="margin: 0px 8px 11px; padding: 0px 0px 0px 23px; overflow: hidden; "><li style="padding: 0px; margin: 0px; ">There is clear potential to derive mortality-based failure to rescue (FTR) indicators for surgical patients from routine administrative data in England</li><li style="padding: 0px; margin: 0px; ">Our indicator, based on the United States' Agency for Healthcare Research and Quality definition, is worthy of further exploration as a potentially valid safety measure</li><li style="padding: 0px; margin: 0px; ">FTR indicators may offer some advantages over standardised mortality measures (such as the Hospital Standardised Mortality Rate) for surgical patients and can, therefore, add to the range of indicators of hospital performance that are available</li><li style="padding: 0px; margin: 0px; ">Unadjusted FTR rates cannot be used to compare the quality of care between hospitals</li><li style="padding: 0px; margin: 0px; ">FTR does not appear to be a specifically nurse-sensitive indicator</li></ol></div><div style="margin-top: 0px; margin-right: 0px; margin-bottom: 10px; margin-left: 0px; font-size: 0.923em; color: rgb(51, 51, 51); font-family: Verdana, Arial, Helvetica, sans-serif; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: 18px; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; background-color: rgb(255, 255, 255); "> <br class="webkit-block-placeholder"></div><p style="margin: 0px 0px 10px; font-size: 0.923em; color: rgb(51, 51, 51); font-family: Verdana, Arial, Helvetica, sans-serif; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: 18px; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; background-color: rgb(255, 255, 255); ">Failure to rescue (FTR) refers to a death after a treatable complication. The rate of FTRs in surgical patients derived from routine administrative data is recognised as an important indicator of patient safety by the United States' Agency for Healthcare Research and Quality. It holds the promise of being more sensitive to the quality of care in a hospital than either conventional mortality or complication rates (Silber et al, 2007).<br>In this Policy+ we draw on findings from a recent report from the National Nursing Research Unit to consider whether the FTR rate can be used in England (Jones et al, 2011).</p><h2 style="font-weight: normal; font-family: 'Times New Roman', Times, Georgia, serif; font-size: 2em; line-height: 28px; margin: 0px 0px 13px; color: rgb(0, 0, 0); font-style: normal; font-variant: normal; letter-spacing: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; background-color: rgb(255, 255, 255); ">What do FTR rates indicate?</h2><p style="margin: 0px 0px 10px; font-size: 0.923em; color: rgb(51, 51, 51); font-family: Verdana, Arial, Helvetica, sans-serif; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: 18px; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; background-color: rgb(255, 255, 255); ">Some deaths in hospital are inevitable. Much of the difference in death rates between hospitals has little to do with differences in the quality of care that people receive however, but is more related to the degree of illness and co-morbidity of patients who are receiving treatment, together with their level of vulnerability. Measures like the Hospital Standardised Mortality Rate try to account for this using statistical techniques, but no statistical adjustment can ever be perfect. <br>The rate of avoidable deaths among surgical patients with treatable complications - another way of referring to FTR - offers a different way of exploring how a hospital performs; this is one that relates to a specific group of patients and may offer some advantages.<br>For people undergoing surgery, the chance of developing a complication, like bleeding or pneumonia, is strongly related to factors such as their age or an underlying condition. Although complications are often a result of patient characteristics, however, the ability of a hospital to successfully treat a complication once it occurs is strongly related to the quality of care provided (Silber et al, 2007). The FTR indicator is intended to show how well hospitals perform once the complication occurs.<br>The potential significance of the FTR rate is reflected in recent reports and research, which emphasise the complexity of responding to patients who are deteriorating and highlight potential points of failure, including:</p><ul style="margin: 20px 0px; padding-left: 0px; list-style: none; overflow: hidden; color: rgb(51, 51, 51); font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 13px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: 18px; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; background-color: rgb(255, 255, 255); "><li style="background-image: url(http://www.nursingtimes.net/magazine/graphics/breadcrumb-bg.gif); padding: 0px 0px 0px 9px; margin: 0px; display: block; background-position: 0px 7px; background-repeat: no-repeat no-repeat; ">Not taking observations;</li><li style="background-image: url(http://www.nursingtimes.net/magazine/graphics/breadcrumb-bg.gif); padding: 0px 0px 0px 9px; margin: 0px; display: block; background-position: 0px 7px; background-repeat: no-repeat no-repeat; ">Not recording observations;</li><li style="background-image: url(http://www.nursingtimes.net/magazine/graphics/breadcrumb-bg.gif); padding: 0px 0px 0px 9px; margin: 0px; display: block; background-position: 0px 7px; background-repeat: no-repeat no-repeat; ">Not recognising early signs of deterioration;</li><li style="background-image: url(http://www.nursingtimes.net/magazine/graphics/breadcrumb-bg.gif); padding: 0px 0px 0px 9px; margin: 0px; display: block; background-position: 0px 7px; background-repeat: no-repeat no-repeat; ">Not communicating observations (Luettel et al, 2007).</li></ul><p style="margin: 0px 0px 10px; font-size: 0.923em; color: rgb(51, 51, 51); font-family: Verdana, Arial, Helvetica, sans-serif; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: 18px; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; background-color: rgb(255, 255, 255); ">For these reasons, FTR has often been considered particularly sensitive to the quality and quantity of nursing care that is available to patients (Griffiths et al, 2008).</p><h2 style="font-weight: normal; font-family: 'Times New Roman', Times, Georgia, serif; font-size: 2em; line-height: 28px; margin: 0px 0px 13px; color: rgb(0, 0, 0); font-style: normal; font-variant: normal; letter-spacing: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; background-color: rgb(255, 255, 255); ">How are FTR rates measured?</h2><p style="margin: 0px 0px 10px; font-size: 0.923em; color: rgb(51, 51, 51); font-family: Verdana, Arial, Helvetica, sans-serif; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: 18px; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; background-color: rgb(255, 255, 255); ">FTR rates used for both research purposes and as quality indicators are typically derived from hospital administrative databases. However, their validity can be compromised if the coding of secondary diagnoses (through which complications are identified) is poor; this is because the indicator relies on the identification of a group of patients who experience particular complications. Less-detailed coding of diagnoses means less chance that complications have been recorded. Previously, it has been concluded that English hospital data were unsuitable for deriving FTR measures, primarily because of low rates of coding (McKee et al, 1999).<br>In our study we aimed to assess whether the conclusions made about deriving FTR rates for surgical patients from English hospital data from 1996-97 still hold when using more recent data (until March 2009), and whether there was evidence that the rates derived were indicative of quality. <br>As a response to concerns about low rates of coding secondary diagnoses, we used alternative approaches that have been proposed, including:</p><ul style="margin: 20px 0px; padding-left: 0px; list-style: none; overflow: hidden; color: rgb(51, 51, 51); font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 13px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: 18px; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; background-color: rgb(255, 255, 255); "><li style="background-image: url(http://www.nursingtimes.net/magazine/graphics/breadcrumb-bg.gif); padding: 0px 0px 0px 9px; margin: 0px; display: block; background-position: 0px 7px; background-repeat: no-repeat no-repeat; ">Assuming that all surgical deaths are FTR (Silver et al, 2007); and</li><li style="background-image: url(http://www.nursingtimes.net/magazine/graphics/breadcrumb-bg.gif); padding: 0px 0px 0px 9px; margin: 0px; display: block; background-position: 0px 7px; background-repeat: no-repeat no-repeat; ">Using extended hospital stays that fall well outside the average range as an (indirect) indicator of FTR (Rafferty et al, 2007).</li></ul><p style="margin: 0px 0px 10px; font-size: 0.923em; color: rgb(51, 51, 51); font-family: Verdana, Arial, Helvetica, sans-serif; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: 18px; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; background-color: rgb(255, 255, 255); ">We used statistical techniques that allowed us to determine associations between FTR rates and a range of quality-related organisational factors derived from routine NHS data; these included staffing variables such as the numbers of nurses and doctors per bed, teaching status of the hospital and nursing staff stability.</p><h2 style="font-weight: normal; font-family: 'Times New Roman', Times, Georgia, serif; font-size: 2em; line-height: 28px; margin: 0px 0px 13px; color: rgb(0, 0, 0); font-style: normal; font-variant: normal; letter-spacing: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; background-color: rgb(255, 255, 255); ">What do the English hospital data reveal?</h2><p style="margin: 0px 0px 10px; font-size: 0.923em; color: rgb(51, 51, 51); font-family: Verdana, Arial, Helvetica, sans-serif; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: 18px; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; background-color: rgb(255, 255, 255); ">Our findings suggest that FTR indicators can be derived from English hospital data and that low levels of recording of secondary diagnoses are no longer a significant obstacle. We found:</p><ul style="margin: 20px 0px; padding-left: 0px; list-style: none; overflow: hidden; color: rgb(51, 51, 51); font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 13px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: 18px; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; background-color: rgb(255, 255, 255); "><li style="background-image: url(http://www.nursingtimes.net/magazine/graphics/breadcrumb-bg.gif); padding: 0px 0px 0px 9px; margin: 0px; display: block; background-position: 0px 7px; background-repeat: no-repeat no-repeat; ">FTR rates are not significantly correlated with the average number of secondary diagnoses coded, which suggests an absence of systematic bias caused by coding practices;</li><li style="background-image: url(http://www.nursingtimes.net/magazine/graphics/breadcrumb-bg.gif); padding: 0px 0px 0px 9px; margin: 0px; display: block; background-position: 0px 7px; background-repeat: no-repeat no-repeat; ">Strong year-on-year correlation for FTR rates in recent years, which suggests a degree of stability consistent with the rate reflecting an underlying characteristic of hospital performance;</li><li style="background-image: url(http://www.nursingtimes.net/magazine/graphics/breadcrumb-bg.gif); padding: 0px 0px 0px 9px; margin: 0px; display: block; background-position: 0px 7px; background-repeat: no-repeat no-repeat; ">A number of associations between the FTR indicators and presumed markers of quality, some of which have been demonstrated in previous work in the United States (Jones et al, 2011).</li></ul><p style="margin: 0px 0px 10px; font-size: 0.923em; color: rgb(51, 51, 51); font-family: Verdana, Arial, Helvetica, sans-serif; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: 18px; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; background-color: rgb(255, 255, 255); ">However, not all the relationships we observed are clearly or plausibly indicative of variations in quality. It seems likely that there are confounding variables that were not accounted for in our models. Any FTR indicator would need to be adjusted for age and other patient-level factors before coming to a final judgement. <br>Non-risk adjusted FTR rates cannot be used to make comparisons between providers.<br>It is notable that previous work, which showed that higher nurse staffing was associated with lower levels of FTR, did not consider medical staffing (Silber et al, 2007). Although we observed a similar association when considering nursing in isolation, the association disappeared when we controlled for other factors. Higher levels of clinically qualified staff (doctors plus nurses) were associated with lower levels of FTR, and a higher nurse-doctor ratio was associated with higher rates of FTR. <br>Although our extended-stay FTR measure performed well in some respects, as there are no longer specific problems with secondary coding, there is no clear advantage for using this over the mortality-based measures. As an indicator of hospital performance, FTR is potentially linked to a number of factors beyond the control of the hospital, such as provision of community services. In addition, the absence of any association with the mortality-based indicators suggests that the measure based on the length of stay is not acting as a proxy of FTR as originally conceived.</p><h2 style="font-weight: normal; font-family: 'Times New Roman', Times, Georgia, serif; font-size: 2em; line-height: 28px; margin: 0px 0px 13px; color: rgb(0, 0, 0); font-style: normal; font-variant: normal; letter-spacing: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; background-color: rgb(255, 255, 255); ">Conclusion</h2><p style="margin-top: 0px; margin-right: 0px; margin-bottom: 10px; margin-left: 0px; font-size: 0.923em; color: rgb(51, 51, 51); font-family: Verdana, Arial, Helvetica, sans-serif; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: 18px; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; background-color: rgb(255, 255, 255); position: static; z-index: auto; ">Further work is required to develop and validate FTR as a quality indicator and develop and test risk-adjustment models.</p></div><a href="http://www.nursingtimes.net/can-failure-to-rescue-be-a-key-indicator-of-patient-safety/5038653.article">http://www.nursingtimes.net/can-failure-to-rescue-be-a-key-indicator-of-patient-safety/5038653.article</a><div style="font-family: Helvetica; font-size: 14px; color: black; text-align: left; "><br class="webkit-block-placeholder"></div>

Can failure to rescue be a key indicator of patient safety? | Practice | Nursing Times

A look at whether administrative data in English hospitals contain enough information to reliably report "failure to rescue" rates...

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Atul Gawande: Failure and Rescue : The New Yorker

<base href="data:"><div style="color: black; text-align: left; "><p style="color: rgb(0, 0, 0); font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: 15px; orphans: 2; text-align: left; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; "><em>The following was delivered as the commencement address at Williams College on Sunday, June 3rd.</em></p><p style="color: rgb(0, 0, 0); font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: 15px; orphans: 2; text-align: left; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">We had a patient at my hospital this winter whose story has stuck with me. Mrs. C. was eighty-seven years old, a Holocaust survivor from Germany, and she'd come to the emergency room because she'd suddenly lost the vision in her left eye. It tells you something about her that she was at work when it happened—in the finance department at Sears.</p><p style="color: rgb(0, 0, 0); font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: 15px; orphans: 2; text-align: left; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">She'd worked her entire life. When her family left Nazi Germany, they narrowly avoided the concentration camps but ended up among twenty thousand Jewish refugees relocated to the Shanghai ghetto in Japanese-occupied China. She was a teen-age girl and spent eight years there, helping her family just to live and survive, until liberation in September, 1945. Denied a formal education, she worked as a seamstress upon admission to the United States. She rose to head seamstress at Bloomingdale's in Chestnut Hill, outside Boston. She married at twenty-three, had two sons, and was widowed at forty-four. She herself remained in remarkably good health.</p><p style="color: rgb(0, 0, 0); font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: 15px; orphans: 2; text-align: left; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">At eighty-seven, she still lived independently in a second-floor apartment in Norwood, Massachusetts. She drove a Honda Civic. She did all her own shopping and cooking. And she still worked—three and a half days a week at Sears, doing office work, and her other weekdays volunteering at New England Sinai Rehabilitation Hospital.</p><div id="entry-more" style="color: rgb(0, 0, 0); font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: 15px; orphans: 2; text-align: left; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; "><p>She was sitting at her desk at Sears when the vision in her left eye went completely black. It came back after three minutes. She dismissed the episode, but the next day the same thing happened again, only this time the vision didn't come back. Her doctor sent her to our emergency room, where she was suspected to have had a stroke caused by a severe atherosclerotic blockage of the carotid artery in her neck. She needed urgent surgery to open the blockage. She thought hard before agreeing to it. She had great fear of the risks and what they could take away from her life. But she had greater fear of what her condition might take away. Being able to remain independent, work, and contribute in some way was most important to her, and her best chance of preserving this was to act.</p><p>The operation went remarkably well. There were no problems at all. She was weak afterward, but the next day she ate, got out of bed, felt fine. The day after that, she seemed ready to leave the hospital. But she complained that constipation was making her nauseated and uncomfortable. The team tried laxatives, but they did nothing, and her belly only became more painful.</p><p>A young resident was the one who, looking at her, felt that something wasn't right. In fact, this wasn't constipation at all, but a disaster from a strange complication. Her stomach had twisted on itself, pulled up into her chest, and become trapped—a condition known as a gastric volvulus. Worse, an ulcer seemed to have formed in the lining of her stomach and ruptured into her chest. This is catastrophic for anyone, let alone an eighty-seven-year-old woman. The textbooks describe an up to eighty-per-cent fatality rate.</p><p>Yet she did survive. In fact, she left the hospital with her son within a week. And the more I reflect on the story of how that was made possible, the more I think that the story is relevant to all of us, whatever our walks of life.</p><p>When I was nearing the end of medical school, I decided to go into surgery. I had become enthralled by surgeons, especially by their competence. The source of their success, I believed, was their physical skill—their hand-eye coördination and fine-motor control. But it wasn't, I learned in residency training. Getting the physical skills is important, and they take some time to practice and master, but they turn out to be no more difficult to learn than those that Mrs. C. mastered as a seamstress. Instead, the critical skills of the best surgeons I saw involved the ability to handle complexity and uncertainty. They had developed judgment, mastery of teamwork, and willingness to accept responsibility for the consequences of their choices. In this respect, I realized, surgery turns out to be no different than a life in teaching, public service, business, or almost anything you may decide to pursue. We all face complexity and uncertainty no matter where our path takes us. That means we all face the risk of failure. So along the way, we all are forced to develop these critical capacities—of judgment, teamwork, and acceptance of responsibility.</p><p>In commencement addresses like this, people admonish us: take risks; be willing to fail. But this has always puzzled me. Do you want a surgeon whose motto is "I like taking risks"? We do in fact want people to take risks, to strive for difficult goals even when the possibility of failure looms. Progress cannot happen otherwise. But how they do it is what seems to matter. The key to reducing death after surgery was the introduction of ways to reduce the risk of things going wrong—through specialization, better planning, and technology. They have produced a remarkable transformation in the field. Not that long ago, surgery was so inherently dangerous that you would only consider it as a last resort. Large numbers of patients developed serious infections afterward, bleeding, and other deadly problems we euphemistically called "complications." Now surgery has become so safe and routine that most is day surgery—you go home right afterward.</p><p>But there continue to be huge differences between hospitals in the outcomes of their care. Some places still have far higher death rates than others. And an interesting line of research has opened up asking why.</p><p>Researchers at the University of Michigan discovered the answer recently, and it has a twist I didn't expect. I thought that the best places simply did a better job at controlling and minimizing risks—that they did a better job of preventing things from going wrong. But, to my surprise, <a href="http://www.nejm.org/doi/full/10.1056/NEJMsa0903048" style="color: rgb(0, 0, 0); text-decoration: none; ">they didn't</a>. Their complication rates after surgery were almost the same as others. Instead, what they proved to be really great at was <i>rescuing</i> people when they had a complication, preventing failures from becoming a catastrophe.</p><p>Scientists have given a new name to the deaths that occur in surgery after something goes wrong—whether it is an infection or some bizarre twist of the stomach. They call them a "failure to rescue." More than anything, this is what distinguished the great from the mediocre. They didn't fail less. They rescued more.</p><p>This may in fact be the real story of human and societal improvement. We talk a lot about "risk management"—a nice hygienic phrase. But in the end, risk is necessary. Things can and will go wrong. Yet some have a better capacity to prepare for the possibility, to limit the damage, and to sometimes even retrieve success from failure.</p><p>When things go wrong, there seem to be three main pitfalls to avoid, three ways to fail to rescue. You could choose a wrong plan, an inadequate plan, or no plan at all. Say you're cooking and you inadvertently set a grease pan on fire. Throwing gasoline on the fire would be a completely wrong plan. Trying to blow the fire out would be inadequate. And ignoring it—"Fire? What fire?"—would be no plan at all.</p><p>In the BP oil disaster in the Gulf of Mexico two years ago, all of these elements came into play, leading to the death of eleven men and the spillage of five million barrels of oil over three months. According to the <a href="http://www.newyorker.com/online/blogs/newsdesk/2012/06/www.boemre.gov/pdfs/maps/dwhfinal.pdf" style="color: rgb(0, 0, 0); text-decoration: none; ">official investigation</a>, there had been early signs that the drill pipe was having problems and was improperly designed, but the companies involved did nothing. Then, on the evening of April 20, 2010, during a routine test of the well, the rig crew detected a serious abnormality in the pressure in the drill pipe. They watched it and took more measurements, which revealed a number of other abnormalities that signal a "kick"—an undetected pressure buildup. But it was two hours before they recognized the seriousness of the situation—two hours without a plan of action.</p><p>Then, when they did recognize the trouble, they sent the flow through a piece of equipment that can't handle such pressures. The kick escalated to a blowout, and the mud-gas mix exploded. At that point, emergency crews went into action. But for twelve minutes, no one sounded a general alarm to abandon the rig, leading directly to the loss of eleven lives in a second explosion.</p><p>There was, as I said, every type of error. But the key one was the delay in accepting that something serious was wrong. We see this in national policy, too. All policies court failure—our war in Iraq, for instance, or the effort to stimulate our struggling economy. But when you refuse to even acknowledge that things aren't going as expected, failure can become a humanitarian disaster. The sooner you're able to see clearly that your best hopes and intentions have gone awry, the better. You have more room to pivot and adjust. You have more of a chance to rescue.</p><p>But recognizing that your expectations are proving wrong—accepting that you need a new plan—is commonly the hardest thing to do. We have this problem called confidence. To take a risk, you must have confidence in yourself. In surgery, you learn early how essential that is. You are imperfect. Your knowledge is never complete. The science is never certain. Your skills are never infallible. Yet you must act. You cannot let yourself become paralyzed by fear.</p><p>Yet you cannot blind yourself to failure, either. Indeed, you must prepare for it. For, strangely enough, only then is success possible. When Mrs. C.'s abdominal pain turned to catastrophe, for instance, my colleagues were prepared. Now, they weren't prepared for anything so odd as the idea that her stomach would have wound on itself like a balloon twisted too tight. In fact, when the surgical resident told Mrs. C.'s surgeon that he was concerned about the way her abdomen felt on his exam, the surgeon thought he was being alarmist. She'd been doing great just the day before. And what could go wrong in someone's belly after neck surgery? He'd never seen a serious belly problem in such circumstances.</p><p>But the surgeon was humble enough to understand that he could. You never really know what way trouble can strike. So he listened. He allowed the resident to order a scan. The team made sure it was expedited. When it showed the queer twist, no one dismissed it. They got help from another surgeon immediately. They had her on an operating table within two hours.</p><p>Nothing went exactly perfectly. There was still a good deal of fumbling around as they tried to sort out what was really going on and what would need to be done. For a time, they hoped for a small, short procedure, using just a scope and avoiding a big operation. It would have been an inadequate plan—perhaps even the completely wrong one. But they avoided the worst mistake—which was to have no plan at all. They'd acted early enough to buy themselves time for trial and error, to figure out all the steps required to get her through this calamity. They gave her and themselves the chance to rescue success from failure.</p><p>I spoke to Mrs. C. a couple days ago, and she gave me permission to tell you her story. She's living with her son now. She turned eighty-eight this past April. With her vision gone in her left eye, she can no longer work or drive, and she misses both greatly. "I'm not the same person I used to be," she told me. She doesn't like being dependent on others, even for just a ride. But she has otherwise returned to leading a life of her own. She enjoys her family, especially her grandchildren. She's even looking for ways to volunteer again. "Life is not perfect, but it is good," she said.</p><p>As you embark on your path from here, you are going to take chances—on a relationship, a job, a new line of study. You will have great hopes. But things won't always go right.</p><p>When I graduated from college, I went abroad to study philosophy. I hoped to become a philosopher, but I proved to be profoundly mediocre in the field. I tried starting a rock band. You don't want to know how awful the songs I wrote were. I wrote one song, for example, comparing my love for a girl to the decline of Marxism. After this, I worked in government on health-care legislation that not only went nowhere, it set the prospect of health reform back almost two decades.</p><p>But the only failure is the failure to rescue something. I took away ideas and experiences and relationships with people that profoundly changed what I was able to do when I finally found the place that was for me, which was in medicine.</p><p>So you will take risks, and you will have failures. But it's what happens afterward that is defining. A failure often does not have to be a failure at all. However, you have to be ready for it—will you admit when things go wrong? Will you take steps to set them right?—because the difference between triumph and defeat, you'll find, isn't about willingness to take risks. It's about mastery of rescue.</p><div><br class="webkit-block-placeholder"></div></div></div><a href="http://www.newyorker.com/online/blogs/newsdesk/2012/06/atul-gawande-failure-and-rescue.html?printable=true&currentPage=all">http://www.newyorker.com/online/blogs/newsdesk/2012/06/atul-gawande-failure-and-rescue.html?printable=true¤tPage=all</a><div style="font-family: Helvetica; font-size: 14px; color: black; text-align: left; "><br class="webkit-block-placeholder"></div>

Atul Gawande: Failure and Rescue : The New Yorker

The following was delivered as the commencement address at Williams College on Sunday, June 3rd. We had a patient at my hospital this winter...

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Educate, Don't Condemnate

The Kansas City Chiefs fans are getting a lot of flack today for how they reacted to their own quarterback's injury. When Matt Cassel went down with a possible head injury, the KC fans cheered the injury instead of showing the normal respect shown to a player on either the home <i>or</i> visiting side.<br /><br />These may have been the same Kansas City fans who, earlier in the week, came out in droves to cheer on Detroit Tigers third baseman Miguel Cabrera as he accomplished the Triple Crown. What makes the two of them different?<br /><br />I believe that it all depends on how you teach. People were keenly aware of the magnitude of Cabrera's accomplishment - and instead of booing an opposing player, they cheered the accomplishment.<br /><br />On the other hand, Chiefs fans were expressing frustration in a way that may have been inappropriate - especially if Cassel's injury had been worse. But they didn't <i>know</i> how bad the injury was. And maybe - unfortunately - it was because these fans hadn't been educated over how to act when a player goes down with a serious injury.<br /><br />When you take your children to a game (from any sport) do you set a good example? Do you show your support to players with big accomplishments? Or do you boo mercilessly even if it's your player? Have you taught them how to act when they are playing their pee-wee sport? Have you taken some time this morning, while watching the KC slamming on <i>Sportscenter</i>, to talk to your kids or coworkers over how they should have reacted?<br /><br />I've heard people say that they have "the right" because of how much their tickets cost, or how much time they've invested in the team. And I kind of think that's stupid. Let's keep our sane heads and not put us up on a pedestal because we made a choice to pay money to watch a bunch of men play a sport. If you're going to pay the money, the least you can do is show you deserve to be there, cheering your players and the sport. <i>Earn</i> the chance to watch and cheer. <i>Educate</i> those around you the proper way to watch and cheer. Let's bring back some civility to watching and cheering the sport that you love.<br /><br /><br />

Educate, Don't Condemnate

The Kansas City Chiefs fans are getting a lot of flack today for how they reacted to their own quarterback's injury. When Matt Cassel we...

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