Here's to you!

Ben Franklin is credited with saying,

"Beer is proof that God loves us and wants us to be happy."

So here's a picture of the beers my husband and I will drink tonight, lifting a glass to support the President, the professor, and the police officer whose small get together this evening is something worth emulating.

Here's to saying, "I may have been the one who messed up (or maybe it was you this time). Let's try to make things better as we go forward."

Cheers. God loves you and wants you to be happy.

Truth, like rain, does not care who gets wet

Okay, I'm feeling grumpy today. And my mood didn't improve when, against my better judgement, I opened a "this-is-for-real" chain e-mail and found this:

The actress Natasha Richardson died after falling while skiing in Canada. It took eight hours to drive her to a hospital. If Canada had our healthcare she might be alive today. In the United States, we have medical evacuation helicopters that would have gotten her to the hospital in 30 minutes.

We're fortunate to live in the United States where we're free to form and express opinions. Like whether the healthcare reform measures on the table are, indeed, the right way to go. I'm still working on an opinion, learning more about what's in the package and how it will effect dimensions of care that are important to me. Like, will the changes make healthcare safer? More effective? Timely? Efficient? Patient-centered? Equitable?

It's no secret that I've been dissatisfied, personally and professionally, with the bang we get for the buck under the highly fragmented and hard-to-access system we currently have.

And, no, I'm not going to Canada.

But I do know a thing or two about Canada, being married to an ex-pat Canadian for a quarter-century and all that comes with that.

Canada is relatively easy to find on comparative health outcome rosters (they're usually a goodly number of notches ahead of the U.S. in measures of population health like infant mortality rates and life expectancy). Oh, and Canadians do pretty well in dollars spent, too (in 2005, using 9.9% of their GDP on healthcare relative to the U.S.'s 15.3%).

All citizens in Canada recently got free online access to the Cochrane Library, where credible studies are synthesized and results shared (using both highly technical language that appeals to researchers and with words that make it easy for consumers to understand complex topics). So Canadians understand concepts like "due date" and "hospice care" which is why, perhaps, they spend less money fixing what ain't broke and trying to fix things that can't be fixed. Don't know for sure, just a guess.

Empowering citizens by ensuring they have access to high-end, evidence-based medical information is not particularly sexy or glamorous (especially when compared to the health education we enjoy in the U.S. where advertisements portray middle aged men who can't pee as the next generation of Outward Bound campers).

One pay-off is that with credible information, Canadians--and others who use facts to inform their decisions--increase their ability to make satisfying, even life-preserving, decisions. It's helpful to know, for example, that more than 10% of the U.S. air ambulance helicopter fleet crashed between 1995 and 2000. And that the safety of air evacs, to this day, is below--far, far below--what passengers on craft subject to FAA oversight enjoy.

Because it's big, fast, and glamorous doesn't make it necessary. And making it subject to regulatory oversight doesn't have to diminish its safety or effectiveness. Outcome data are helpful to know, should you have to weigh the risks and benefits of air transport--and other high tech gadgetry--to facilitate the care of someone in your family.

Frankly, just knowing that Canadians have helicopters might be a step in the right direction.

Please mess with Texas

When I was a Labor & Delivery nurse, and long before I had a better conceptual framework for understanding quality in healthcare, I learned two words that summed up what families valued during their childbirth experiences: "safe" and "satisfying." While these weren't all-inclusive quality markers, they're foundational elements that signaled quality. They still do.

"Satisfying" is a concept that belongs to individuals. The way pain is relieved, how much restoration of function is enough, what a good birth, or a peaceful death look like are outcomes subject to interpretation, outcomes rightly defined by individuals. So long as they're competent to make decisions and their choices don't interfere with others, consumers should own "satisfying."

On the other hand, "safe" can't venture far in territory that's defined by the perception of individuals. Here's one reason why: Each of us is a statistical sample of one. A good outcome may arise because the people and processes effecting the experience are fit, robust, and reliable. In a word, safe. It's also plausible that one good outcome represents a lucky spin of a very damaged wheel. When comparative processes are absent, one outcome tells little about safety. This is why licensing, professional standards, regulatory oversight, benchmarking, quality metrics, error analysis, and peer-review processes are deeply rooted in industries that post excellent safety records. Measures like these unearth information from a variety of sources, revealing data not readily apparent to individual consumers.

Quality assurance processes are far less perfect in healthcare than they are in other high-stakes, high-consequence industries. In the US, over 100,000 people die each year as a result of medical error and healthcare acquired infections, adverse events that cost billions and rob citizens of peace when they are most vulnerable. In healthcare, we're struggling to align individual competency, personal accountability, and good design in a way that's more reliable, better able to deliver the predicted outcome, and, well, safer than it currently is.

Which is why a case in Texas, in which two registered nurses face felony charges for good-faith actions aimed at protecting patients, should concern you. The nurses, both employed at a county hospital, reported concerns about a physician's practice to the Texas Medical Board. Their report included numbers (but not names of patients) that medical board officials would need to identify medical records for review. As a result, both nurses:

• were charged with "misusing official information" (criminal charges arising from the act of disclosing medical record numbers to the Texas Medical Board)
• were fired from their jobs
• face $10,000 fines and up to ten years imprisonment, if convicted

Let me be clear here: A nurse's report of concern about a physician's practice does not constitute a professional sanction. Reports of concern are pieces of data, not judgments. In a healthy system, reports of concern about licensed professionals result in peer-review. In a sick system, reports of concern result in acts that punish those who raise them (and intimidate those who might consider raising similar concerns in the future).

One of the biggest challenges to healthcare safety and quality is under-appreciation and under-reporting of things that have the potential to cause harm. Healthcare is a "no harm, no foul" game, and playing by these rules means we often miss the chance to fix a known problem before actual harm occurs.

In a culture where safety is valued, people who report things that are outside of perceived norms are highly valuable players. But in Winkler County, Texas, they could be criminals.

You can read more about this case, the charges, and contribute to the nurses' legal defense fund, set up by the Texas Nurses' Association, by clicking here.

Grand Rounds visits the Tour de France

Tour on over to Grand Rounds, hosted today in Australia by Captain Atopic Degranulated. You'll get schooled on things cycling, plus have a chance to see who's wearing the yellow jersey, errr, white coat, in the blogosphere.

Healthcare reform is a hot topic, as stakeholders, most with big dogs in the fight, errr, race, jockey for position. One post to visit is It's About the Patients, Stupid where Mother Jones, RN reminds people why nurses remain the healthcare professionals most trusted by the American public.

Enjoy today's ride!

I'm so very sorry

Tomorrow is National Patient Safety Day, a time to remember people who have been harmed while seeking care or cure. It's also a time to consider how people--patients, providers, and those who have been or will someday be patients--can improve the care delivery system and eradicate preventable harm.

Patients are infrequently the target of professionals who intend to harm them. But people, millions of them each year, are nevertheless harmed. I'm sorry for preventable harm that has occurred and sorry for preventable events that loom.

I was a hands-on clinical nurse for a long time. I don't think I've been the last person in a chain of events that resulted in harm to a patient. But I could have been, any healthcare provider could be. Clinicians frequently fly without safety nets, and it's often grace--not structure or safeguards that come when hearts, minds, and wallets open to achieve and sustain reliable processes--that distinguish clinicians with pristine records from those who err. I'm sorry for errors I may not have seen, known to report, and for near-miss events I didn't see as valuable in the fight to eradicate errors.

This morning, it didn't take me long to find a credible account detailing what patients and front line clinicians face each day. In A Nurse's Very Bad Day, New York Times health blogger Teresa Brown, leaves readers with an unflinching picture of what good people who work in, and depend upon, our well-intended but unreliable system regularly face. I'm sorry that a strong, competent nurse cries like a soldier at the end of a battle in civilian territory. I'm sorry for the risks her patients face.

The answer to how millions of people are harmed from preventable medical errors each year lies in all the tiny details that went wrong in Teresa's Brown day. These answers are not easy, cheap, sexy, or full of star power.

People, like me, who are sorry about the harm that has occurred--particularly those who seek to reform healthcare--should harness this sorrow and transform the system into something that's not so regrettable.

In the meantime, let me just say: I'm sorry. I'm so very, very sorry.

California is full of bad actors

California is full of bad actors. But maybe I should tell you something you don't already know.

In case you missed it last week, California's Governor Schwarzenegger replaced most members of the State Nursing Board. This action followed an LA Times report detailing the board's inability to evaluate and rule on allegations of professional misconduct by registered nurses in a timely fashion. A day or two later, two California state senators announced they were crossing party lines to author legislation that would reform the state's Medical Peer Review process. Both actions were widely reported under headlines forecasting improvements in "patient safety."

These initiatives--and others focusing on the processes used to evaluate and re-evaluate professionals who may be "bad actors"--are indeed part of the fabric that protects the safety of patients. But equating occasional long reaches down a dark foxhole with "patient safety" is a huge disservice, a distraction almost, relative to what the science of patient safety really is and what it takes to get the job done.

Patient safety is really the science of reliability applied to healthcare: How does a system operationalize processes in order to achieve a stated goal? It's not "How to cure cancer?" but rather, "How do we ensure that a patient is not killed by an overdose of chemotherapy while undergoing treatment to be cured of cancer?"

Goals like these rely on competent individuals, but they are not achieved--in a reliable fashion--solely because of them. (Having a sober pilot does not guarantee a safe flight.) Measures that focus on individuals' performance and behavioral choices should not be equated with the full spectrum of activities needed to improve the reliability of healthcare.

As healthcare reform ramps up, patients and professionals should be looking for measures--and funding--to enhance patient safety that are wider than a foxhole and constructed in a way that allows existing tunnels to connect.

More than a moment for patients

The third edition of Patients for a Moment is up at Duncan Cross' place. I get fresh insight every time I visit patient blogs and wonder if the healthcare system wouldn't improve if every single blogger shared their most recent experience about being a patient. I have a working title for a post I'm going to write called, If I didn't give birth to you, resist the urge to call me "Mom."

I learned this week about Twitter's potential to provide aggregate data that could be useful in disease management and research. (The majority of people I know still think Twitter is for people who care whether Ashton Kusher buys one or two ply toilet paper.)

In addition to providing real-time information about the bathroom habits of the stars, Twitter could help inform "nature versus nurture" issues. Say you have a child with a difficult-to-manage-and-treat condition, like autism. A condition that could be influenced by things like weather, season, age, stress, medications, exposure to certain foods, chemicals, and so forth.

140 character tweets allow parents and caregivers to send real-time, structured observations to a central repository where others with similar conditions are also tweeting. Data can be aggregated and overlaid with other variables (like barometric pressure; temperature; phase of the moon) with the net effect being more comprehensive information about the state of individuals within the state of the environment they're in.

Sweet. (Tsweet?)

"Seven" things about communication

Yesterday, I posted a comment about the importance of linking high-end IT gadgets, things that often appear to be stand-alones, to the larger whole. I'm sensitive to this since my daughter has been hearing with a cochlear implant for the past 12 years.

I know from experience that it's easy to think you're being heard when you call a child to dinner and she shows up. She comes because she heard you say, "Time for dinner!" Or she heard something and decided to check it out since dinner is normally served at this time. Or she heard nothing but something smelled good. The outcome "showing up for dinner" is the same in each case. But you'll only replicate the results (and achieve them under tougher conditions) if the first statement is the accurate one.

In healthcare, regulators are focusing on closed-loop communication, techniques that are long-time norms in industries that deliver reliable results. Healthcare workers now have standards that prohibit transmission of high-stakes information--such as chemotherapy orders--by telephone. Clinicians receiving verbal orders have a duty to "read back," and clinicians who have given verbal orders must verify the information has been heard as intended. Other communication-sensitive initiatives include standard pathways and windows of time for notifying providers of critical lab values and radiology findings.

There's been more than a small amount of push-back from clinicians, especially from those who perceive they have never initiated, contributed to, or facilitated an error rooted in poor communication. (Every year, 1.5 million people in the US are harmed by medication errors, a statistic which substantively refutes the notion that entrenched communication patterns are sufficient.)

So I thought I'd share some communication "best practices" from my daughter, a reluctant but seasoned communication expert. She's a college student and, in the summer, the equine director at a residential camp who goes by the name "Seven." Here's what she shares with other camp staff and her campers, consider them seven from Seven:

Tips for Talking to Seven

The numbers below look different even though they're all the number “7.” Hearing with a cochlear implant is like that, too. I (“Seven”) don’t hear exactly like you do. My hearing “looks” different than yours (unless you hear with a cochlear implant, too!).

Even though I can use a cell phone and do many of the same things you do, when I miss words and exchanges that happen in “real time,” I may wind up lost, even though I was “with” you just a minute before. Here are things you can do to help me hear what you’re saying & stay current since I definitely don’t want to miss any of the fun!

I rarely overhear things, especially in noisy places (like the dining hall or a restaurant).

Be sure to talk to me directly when something important—like what we’re doing next or a change in the schedule—pops up.

I’m a really good lip-reader. Let me see your face when you’re talking whenever possible.

I’m “in my zone” when I’m around the horses. I usually know what’s going on or can guess what’s about to happen. So I may look like I’m a better hearer at the barn than I am in other places.

I don’t mind repeating things if you don’t understand me the first time I say them. I often have the same trouble with what you say. :)

I know sign language and will be happy to teach you how to make a “name sign” for yourself and help you learn some signs.

It’s okay to ask me questions about cochlear implants and how I hear.

Grand Rounds & Health IT: The man behind the curtain is..... Forrest Gump?

Good reading awaits at this week's Grand Rounds, where Dr. Joseph Kim invited bloggers to share how IT is changing healthcare.

Healthcare is full of tech-facilitated miracles. I think health care technology's best successes so far lie in applications aimed at individuals. My daughter's cochlear implant is one great example.

A cochlear implant (CI) does not make my daughter a "hearing person." But it certainly gives her the opportunity to access sounds and to make meaning of them in a way that's very similar to what people with normal hearing can do.

Deaf people don't have surgery and wake up "hearing" any more than you buy a computer and become Bill Gates. To realize the full potential of a cochlear implant, a user learns to make meaningful use of the data the implant provides.

Implant users can hear--and grasp the significance of--a toilet flushing almost immediately. But understanding and mastering a complex battery of sounds--like syllables, words, and sentences--has a much longer learning curve. Gaining meaningful use of a cochlear implant also requires concomitant support that's not technical at all: early education for language acquisition and ongoing speech therapy.

Think about another IT-facilitated product that fosters miracles: digital radiography. A lay person can see that digital images are sharper, brighter, more precise than those on old-fashioned films. But knowing what's normal, what's a normal variation, and what requires follow-up takes education and experience, an intimacy with both the imaging device and the anatomy it captures. Like a CI, radiography only becomes meaningful when the data is interpreted, communicated, and factored into a larger whole.

System-level application of IT, a late-comer in healthcare, is likely on a similar journey toward meaningful use. Right now, I'd say health care stakeholders are hearing toilets flush and noticing that some things are brighter than others.

I think there's a lot of other things that could be said about that.

But since I'm feeling a little like Forrest Gump today, I think that's all I'm going to say.

Keeping the Rx train on track

The medication use system is hooked together, kind of like cars on a train. And the cars would be labeled:

• prescribing


• dispensing


• administering


• monitoring
  

Seminal medication error literature suggests that errors originating in the prescribing car account for about 40% of all errors and represent 28% of harm-causing errors. Nearly 1/2 of errors that arise during prescribing are picked up before they reach a consumer, mostly because the cars that follow contain check points and feedback loops to detect and right the error. But this means that a substantial number of errors remain undetected, errors that potentially harm patients, or in some way derail the intended plan of care.

Computerized Prescriber Order Entry (CPOE) holds the promise of increasing the reliability of activities that occur in the prescribing car. Automation ensures that patient allergies, duplication of therapy, and potential drug interactions are considered during each prescribing cycle in a way that reliance on even the most diligent human cannot.

When CPOE's best potential is realized, active errors originating in the prescribing phase will be reduced. So will passive errors that occur when high-stakes drug information is not transmitted across the continuum of care and is not readily available to treating clinicians.

Depending on the outcome of national discussions surrounding the use, the meaningful use, of 20 billion health IT-earmarked dollars, the average Walmart shopper can expect to see universal e-prescribing, ummm, soon. Until e-prescribing is fully implemented, people in the U.S. will live (or not, as the case may be) with hybrid systems.

Here's what I tell consumers to do to decrease the chance that a prescribing error will make it home:

1. When you receive a prescription for a medicine, it should be legible. Ideally, this means that the prescription is sent to your pharmacy electronically and you receive a printed copy. If it's not an electronic system, and you have to hand-carry a prescription to the pharmacy, it should be legible.

A "legible" handwritten copy of a prescription is one you can read. (It's not necessary for you to understand every word, term, or symbol, but you should be able to see and distinguish each word and number clearly). Pharmacists and pharmacy technicians have a lot of specialized knowledge, especially about drug names and products that are currently on the market. But they don't receive CIA-level training to decode poor penmanship. Making "an educated guess" is not what they're supposed to do nor is it what you want them to do. (Think of your prescription like the directions a pilot receives. Would you be willing to taxi to a runway knowing the pilot received directions he couldn't read clearly?)

2. Know what's included on your prescription and why it's important:

• who is prescribing it


• who it is being prescribed for


• the date of birth of the patient (or another identifier in addition to the patient's name)


• known drug & food allergies of the patient


• the name of the drug


• the dose of the drug


• how many pills or how much liquid should be taken in order to achieve the desired dose


• how often the drug should be taken (usually expressed in "times per day" or "times per week")


• the quantity the prescriber is authorizing (how many pills or how much liquid you will receive)


• the number of refills you may receive


• the reason for taking the drug

When your prescriber (the doctor, nurse practitioner, or PA) includes the reason for the drug on the prescription, it provides another layer of information (a redundancy) to help ensure the correct drug is dispensed. 1,400 commonly prescribed drugs appear on lists of regularly confused drugs. Few of these drugs are used for the same purpose. This means that in the event your prescriber doesn't write clearly or the drug name is misread in the pharmacy, the pharmacist performing the final check has another "match point" to help detect an error. In a high-stakes, high-consequence process like medication use, you want lots of checks and double checks. (Medicine may look like candy, but it's not.)

3. Finally, when you pick up a prescription, open the bottle and look at the pills. When you're asked to sign for a prescription, you're likely signing something that says you have no questions and don't require/request additional face time with the pharmacist. Everyone has a least question when picking up a medication, and the question is this: "Did I get the right drug?" Look at the label, or ask that it be read to you. Is this the medicine you expected to get? Is the dose correct? If the name or appearance is different, the pharmacist can explain why (perhaps a generic brand was substituted) or an error that's been set in motion can be detected before you take the medicine home.

Perhaps the most worrisome thing about transitioning to e-prescribing is IT's guiding principle: "garbage in, garbage out." Take a look at this old-fashioned prescription, written just a few months ago for a member of my family.

Although the elements recommended for inclusion in any prescription are easy to list (see above), they are not included on the pre-printed prescription form used by the group of prescribers, a format used by the majority of prescribers in my community. (I blanked out most identifying info but left the "Children's" portion intact to remind myself--and you--that children are among those most at-risk-for-medication-errors and most likely to suffer harm when an error occurs.)

This process is garbage, folks. Just ask the IT person who is trying to automate it.

Where's the engineer of this train wreck?

Every year in the U.S., 1.5 million people are harmed by medication errors, events that add billions of dollars to the healthcare economy. The medication use system we rely on is a lot like a train sent down the tracks without an engineer. Not only was it not "engineered" in the first place, few people on the train understand everything necessary to ensure its safe operation. Worse, most people on board wrongly assume that someone is, indeed, in charge and sit back, assuming they are free to relax and enjoy the ride.

Maximizing the safety of medication use is no short journey. You start with a complex system that involves licensed individuals, crosses the disciplines of medicine, pharmacy, and nursing, is highly regulated, has deep-pocket special interest groups, and requires a high degree of cooperation and communication amongst professionals and consumers. Oh, and to cement your joy, if you include the word "medication" in a sentence, you've just catapulted the instructions out of the range of the fifth grade reading level that health materials are supposed to be written at. ("Medicine," yes. "Medication," no.)

Medications have to be prescribed (or for OTCs, selected by consumers) dispensed, administered, and, in some way, shape, or form, monitored for effectiveness. For warfarin, the rat poison that mitigates inappropriate blood clotting, monitoring involves serial tests run on blood samples. At the other end of the spectrum are birth control pills, where monthly periods suffice. (Sadly, variability is not the friend of reliability.)

Systems engineers speak of "failure points," predictable places where errors are likely to occur. For example, not knowing that a patient takes warfarin when he or she presents for treatment of another condition is a known failure point that can be predicted to result in medication-related harm.

"Failure finding tasks," "performance shaping factors," and "exposure rates," are engineering concepts that rarely make their way into curricula used to prepare healthcare professionals. Yet when it comes to getting desired health outcomes what healthcare professionals know about how a system works may be as important as knowing how a person's system works.

Systems engineers also learn to design work processes to achieve three distinct safety-sensitive outcomes:

1. prevent errors (operative words: barriers, constraints)


2. discover errors set in motion before they cause harm (operative words: redundancy, "failure finding" tasks)


3. mitigate the potential for errors to cause harm (operative words/concepts: recovery, rescue)

There's a host of things that can be done to improve safety when medications are used. But the first step (and remember, this is always the first step) is to recognize that we--all of us--have a problem. If you prescribe, dispense, administer, or take medications, you have a problem: you're riding in a runaway train.

The good news is that the language of systems engineering can be learned, and concepts adopted and adapted to retrofit the medication use system. And you have a role, no matter where you're coming from. I'm going to begin an occasional series, describing specific actions and activities that can be used to strengthen the system. You'll find these posts are indexed with the label "engineering." All aboard? I hope you'll come back soon!

My Purple Door

Three of my four grandparents emigrated to the USA from Sweden, and one of the highlights of my adult life has been reconnecting with cousins in the small village where my father's people have lived for hundreds of years. Sweden is a rural country of 9 million people, with a population size that mirrors my home state of Georgia and a land mass similar to California's.

Sweden's bucolic beauty shares elements of the pacific Northwest, coastal New England, and Alaska. Most remarkable, at least to my American eye, is how Sweden's infrastructure complements its natural beauty. No suburban sprawl, no ribbons of strip malls connecting one group of Walmart shoppers to the next, few fast food outlets beckoning always-hungry, rarely-satiated citizens.


Homes in the country, like the one here that belonged to my great, great grandparents, are usually painted wood. They showcase traditional designs and palates, contributing to a landscape that is even more beautiful than the sum of its parts. (If you get a chance to bet on the color of a house in rural Sweden, choose barn red; light gold; or wedgewood blue. You're going to win.)

One night, while drinking with my cousins, it occurred to me to ask about the social customs and constraints that produced such a holistic landscape. "Stefan," I asked, "What if a Swede wanted to paint his house purple? Could he do that?" My cousin paused to be certain he understood the question, explained a little about local zoning, then said, "But a Swede would never want to paint his house purple."

This led to the telling of a story about the desirability, from the Swedish point of view, of being an average citizen, "a middle Svenson," as my cousin explained it. In Sweden, people are discouraged from living or behaving in ways that substantively distinguish them from their peers. This doesn't mean that individuals aren't creative or expressive. It simply means that one's efforts should reflect established norms, building upon principles, traditions, and aesthetics that have withstood the test of time. A person who painted his house purple would invite unwelcome attention, irrespective of how lovely the shade. So would a person who parked a broken washing machine on his porch.

My cousin's insight helped me understand why the Swedish countryside looks the way it does. The explanation helped me understand a little more about rural Georgia, too.

Culture impacts more than paint colors and where old appliances are laid to rest. Take health outcomes for Georgia and Sweden, two locales that share both population size and challenges that come with providing care in rural settings:

• In Sweden, deaths of infants in the first month of life--a statistic that's considered a reliable marker of overall population health--number 2.1 per 1,000 live births.
  
• In pockets of Georgia, where the least healthy and poorest citizens are clustered, the neonatal death rate is 17 per 1,000.
  
• Some of Georgia's citizens do much better, with neonatal mortality rates in the weathiest suburbs at 4.2 per 1,000.

These comparative health outcome data are especially important for Americans, who, like me, can access highest end healthcare and often believe they have something to lose when the subject of healthcare reform is broached. Sweden's best--a best that represents outcomes for all citizens, not just the healthiest and weathiest--is far better than what the most privileged Georgian can expect.

The take-away? No matter how well you think a market-driven healthcare economy works, it's important to remember that you can't buy what doesn't exist.

My husband, an ex-pat Canadian and naturalized American citizen, worries less than I do about identifying an appropriate healthcare model for Americans to emulate. Americans, he says, are not like anyone else, even though we are, in point of fact, a little bit of everyone else. My husband believes that a uniquely American solution, one that accepts our good intentions, bad behaviors, unparalleled diversity, and independent ways will emerge. I hope he's right.

From the looks of our front door, I kind of need him to be.

Medication safety: It's hard to be (a) patient!

Patients for a Moment is a new blogging round-up, one that collects stories from patients and people interested in the experiences of patients. I joined in this week and shared a short piece about what safer prescribing would look like. There's a lot going on with medication safety in other venues as well. The FDA just heard recommendations from an advisory panel, and it's looking like consumers are going to get some help in managing risks associated with acetaminophen.

A few weeks ago, I listened to an excellent webcast about medication management and safety aimed at health care professionals (click here to go to the link to hear the re-broadcast). In the U.S., approximately 25% of all reported medical errors involve medications. The most important "take-away" I heard occurred when Peter Angood, a physician leader in the patient safety movement (someone intimately familiar with medication safety risk points), shared how his drug history had been botched during a recent outpatient procedure.

The communication infrastructure surrounding medication use is so poor that the system breaks down for patient safety experts with relatively uncomplicated medication profiles undergoing scheduled diagnostic procedures? Yes. Routinely. Bet on it. Good luck to the rest of us.

Dr. Angood's story serves as yet another "call to action" as people in the United States consider how to spend $20 billion dollars to make healthcare IT serve patients and providers in meaningful ways.

Here's the take-away for now: While we await better integration of electronic medication data, go ahead and establish an electronic medication record of your own. ISMP's Consumer Med Safety website, in conjunction with iGuard, offers a free MedSafetyAlert! service for listing and tracking your medications. It's easy to use, and iGuard's medication platform is being adopted by larger electronic medical record systems, meaning that the data you enter will likely "flow through" to more sophisticated e-health record keeping systems (maintained by you, your caregivers, or a healthcare facility).

Based on the information you enter into MedSafetyAlert!, you'll receive tailored alerts and monthly summaries via e-mail. I've used the service for several months, and found it to be simple, non-invasive, and easy-to-access.