Increasing the Speed of Medical Patient Safety Advances in the USA

Bob Latino blatino at RELIABILITY.COM
Wed Nov 12 14:05:12 UTC 2014

Excellent post as usual Rob.  My friends in the Nuke industry refer to this as 'Blind Flashes of the Obvious' (BFO).

When you look at the big picture of how to bring proven, effective innovation and creativity to market faster, so the patients will benefit now; certainly successful models exists from other industry verticals like high technology (e.g. - Apple, Samsung, Dell, etc.).  By the time you buy your iphone or laptop today, it is obsolete as new versions are on deck for the following year.  Again, this is a different industry, but a system is a system.  Academia also have a difficult time in keeping up with current technologies.

I personally don't think that the answer to your question is too difficult, if we were 'King for a Day'.  If the path ahead of us was cleared and we could do what we needed to do, would it be that difficult in concept?

The problem is the number of obstacles in the way to implementing such effective solutions.  Our current regulatory environment, cumbersome internal organizational systems, interdependent politics (internal and external to our business) and the like, create such seemingly insurmountable barriers.  So much so that we feel we don't have the time and will to fight such a battle.  Our systems should be designed to aid such efficiency and effectiveness  in bringing value-added tools/technologies/methodologies to market faster, no debilitate them.

If you were to do an RCA on "Why it took 15 years for the US to accept Australia's proven cure for peptic ulcers?", what kind of latent root causes would you suspect to find?  Same for bringing proven drugs to market?

Robert J. Latino, CEO
Reliability Center, Inc.
blatino at

From: robert bell [mailto:rmsbell at ESEDONA.NET]
Sent: Wednesday, November 12, 2014 12:24 AM
Subject: [IMPROVEDX] Increasing the Speed of Medical Patient Safety Advances in the USA

Increasing the Speed of Medical Safety Advances in the USA
Medical advances are sometimes quick and sometimes painfully slow. There is an estimate now that 440,000 patients are dying of error (including diagnostic) every year in the USA with more being injured. This figure if true has risen from the IOM estimate 15 years ago of an upper limit of 99,000 deaths. And presumably with the Affordable Care Act and more people coming into the system there will be even more deaths occurring.
About 167 years ago Ignaz Semmelweis suggested we wash our hands before seeing patients - it has been said that only 2/3rds of physicians do this today when going from patient to patient in hospitals. The importance of Helicobacter pylori in peptic ulcers and its treatment with antibiotics discovered by Nobel Prize winners Barry Marshall and Robin Warren of Australia took some 15 years to be fully accepted in the US. Also, the length of time it takes to get a new pharmaceutical drug on the market (about 10 - 15 years).  Are such times acceptable when patients are dying?
Here on this list we talk about ways to handle a particular problem. Some will be excellent and life saving advances, but whether they are introduced into hospitals will depend on the enthusiasm of a few and the culture in the hospital in question. And then with normal good idea spread one could expect that idea to take 20 - 30 years to be adopted in all 5,723 hospitals in the US.
So if we want to prevent more deaths we need to introduce ideas that are effective far, far more quickly.
How to do this well is the challenge? The quickest way would seem to be through legislation, but in our gridlocked Washington DC environment, is this possible?
It would seem that numbers are more powerful and that greater co-operation and coalition formation between the Medical Safety Societies would be worth exploring further to see if such an approach would move things along much faster.
It also seems that all or most communications to the list should more often focus on solutions and how to achieve widespread use of something that works. This so that posts are more action oriented.
Further, I would suggest that contributors copy others to help move things along. Ideas can be like seeds in the desert waiting for the right conditions to germinate. Perhaps even establish a good idea website by category. I do not know what the whole solution is in this complicated field but it seems that we need to be experimenting more, communicating more, and doing more, if we want to significantly impact the death and injury toll.
I would also propose that a National Symposium be held to discuss, How to Increase the Speed of Medical Patient Safety Advances.
Would welcome comments.
Robert M. Bell, M.D.



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