Millionaire’s Mission: Joe Kiani Wants Zero Patient Deaths Due to Medical Error

Joe Kiani, founder and CEO of Masimo, is photographed at the company's headquarters in Irvine, California January 27, 2017. Kiani invented non-invasive patient monitoring medical devices. Photo by Kendrick Brinson
Photo by Kendrick Brinson

STAT news reporter USHA LEE MCFARLING recently reported on the work of patient safety advocate Joe Kiani, a millionaire on a mission to solve patient deaths attributed to medical error. I have previously participated in Joe’s annual Patient Safety Summit as a representative of SimGHOSTS, and found the man, the mission, and the organization a powerful voice for improving healthcare. Check out this excerpt of the article by Usha on STAT news:

Joe Kiani likes to point out that the most worn spot on most medical monitoring devices is the mute button. He’s out to change that — and, he hopes, to stop the epidemic of preventable hospital death that kills tens of thousands of Americans each year. It’s not a glamorous cause. And Kiani is not a household name. But he is a multimillionaire with a proven track record of using engineering smarts to fix dogged problems; he made his fortune improving the humble pulse oximeter, which measures oxygen saturation in the blood. Now, he’s pushing a nerdy, but elegant, idea for saving lives: prodding manufacturers of medical devices and electronic records to open their platforms so all the systems can talk to each other.

His tech fix — if widely implemented — could bring order to the cacophony of beeps, buzzes, and blaring alarms that can so overwhelm nurses and doctors that they push “mute” and miss true emergencies. It could make it easier for staff to monitor patients with complex needs. And it could flag, in advance, potentially fatal errors like incorrect dosing and drug allergies. Manufacturers, naturally, aren’t so eager to share their computer code. But Kiani is not one to give up. He stages a glitzy patient safety summit each year, attracting big-name speakers like Bill Clinton and Joe Biden to pound home the need for hospitals to stop killing their patients.

Kiani runs his own medical device company, Masimo, from a building so airy and modern it stood in for Stark Enterprises in the first “Iron Man” movie. “It’s probably better he didn’t become a doctor,” mused Dr. Steven Barker, a professor emeritus of anesthesiology and aeronautical engineer at the University of Arizona who now works as chief science officer for Masimo. “He wouldn’t have saved nearly as many lives.” Soon after graduating, Kiani got a chance to work on pulse oximeters. The geek in him was captivated. “I couldn’t believe you could shine light in your finger and measure oxygen in your blood,” he said. “I just loved the idea.”



When Kiani began to put faces to the statistics, he was shaken. One of those faces belonged to 11-year-old Leah Coufal, who died in December of 2002 at Cedars-Sinai Medical Center in Los Angeles. She’d had routine surgery to correct a mild chest deformity and apparently received a massive dose of fentanyl to control pain — enough to stop her breathing. Her mother, Lenore Alexander, couldn’t talk about Leah’s death for a decade. When she started speaking out, Kiani listened. He was shocked to realize his own daughter — who is fine now — had surgery in the same hospital, with the same surgeon, in the same week as Leah. “That could have been me,” Kiani told the people gathered at his first patient summit in 2013. “It could have been you.”

He was also shocked to find Leah had not been monitored after surgery, not even with a simple pulse oximeter. Another name Kiani couldn’t keep out of his mind at the time was Rory Staunton, a 12-year old from New York who scraped his arm in gym class, then died from a sepsis infection that simple screening tools could have detected.  

How one hospital is beating sepsis and saving lives “He wondered: “Why are people going into hospitals and not coming out?’” said Frederic J. Harris, an electrical engineering professor at San Diego State University who taught Kiani and remains close to him.

He’s working to create the architecture that hospitals could use to network their tens of thousands of devices into what he calls a “truly neutral, two-way plug and play” system. Once those standards are in place, he said, “I’m going to call vendors on their data pledges — very publicly.”

Read the full article on STAT news today


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Media Covers May BMJ Article: “Medical Error 3rd Leading Cause of Death in U.S.” – Call for New Hashtag #SimToZero!

medical errors and simulation

Earlier this month the BMJ published a study by medical researchers from John Hopkins which provided a deeper analysis into the 2014 Journal of Patient Safety. Check out more about the new article here, and listen to this BMJ Podcast interview about the research:

About the Analysis:

Analyzing medical death rate data over an eight-year period, Johns Hopkins patient safety experts have calculated that more than 250,000 deaths per year are due to medical error in the U.S. Their figure, published May 3 in The BMJ, surpasses the U.S. Centers for Disease Control and Prevention’s third leading cause of death—respiratory disease, which kills close to 150,000 people per year. The Johns Hopkins team says the CDC’s way of collecting national health statistics fails to classify medical errors separately on the death certificate.

The researchers are advocating for updated criteria for classifying deaths on death certificates. “Incidence rates for deaths directly attributable to medical care gone awry haven’t been recognized in any standardized method for collecting national statistics,” says Martin Makary, professor of surgery at the Johns Hopkins University School of Medicine and an authority on health reform. “The medical coding system was designed to maximize billing for physician services, not to collect national health statistics, as it is currently being used.”

This publication really caught a lot of media attention:

  • CBS News – “For the study, Makary and his colleagues evaluated four separate studies that analyzed medical death rate data from 2000 to 2008, including one by the U.S. Department of Health and Human Services’ Office of the Inspector General and the Agency for Healthcare Research and Quality. Based on 2013 data on hospitalization rates, they found that of 35,416,020 hospitalizations, 251,454 deaths stemmed from a medical error. They said that adds up to 9.5 percent of all deaths a year in the U.S.”
  • Huffington Post“Unfortunately, this news is not surprising at all. In the medical community, we have seen the consequences of inaccurate diagnoses and medical error for quite some time. While concrete efforts have been made to correct wrong site surgeries and other well publicized issues from the past, not enough has been done to address medical error that results from an incomplete or inaccurate diagnosis. 37% of the cases we review require a change in diagnosis, and over 75% of cases require a change in treatment plan.”
  • CNN – “One reason there’s such a wide range of numbers is because accurate data on these kinds of deaths is surprisingly sparse. That’s in part because death certificates don’t ask for enough data, Makary said. Currently the cause of death listed on the certificate has to line up with an insurance billing code. Those codes do not adequately capture human error or system factors.”
  • Washington Post ““There has just been a higher degree of tolerance for variability in practice than you would see in other industries,” he explained. When passengers get on a plane, there’s a standard way attendants move around, talk to them and prepare them for flight, Sands said, yet such standardization isn’t seen at hospitals. That makes it tricky to figure out where errors are occurring and how to fix them. The government should work with institutions to try to find ways improve on this situation, he said.”

Additional press Coverage spread wide and far…

Unfortunately, many of the articles did NOT cover potential solutions for addressing these avoidable mistakes. As champions of Simulation, we must reach out to these media agencies and remind them that healthcare simulation provides a huge opportunity to better educate and train for improved patient safety outcomes.

With this rare opportunity to maximize such exposure, I encourage you to write in and tweet these media agencies and remind them that simulation is already helping to address many of these problems with the hashtag #SimToZero, highlighting a goal to reduce medical errors to zero through the use of healthcare simulation.

Please join me in this new campaign to create a hashtag supporting
Simulation To Zero Patient Deaths From Medical Error!

Health IT Mistakes Can Hurt Patient Safety

breakdown of medical errors

Over on Health Data Management they recently published a report showing how some Health IT mistakes cause patient safety errors. As simulation touches so much technology and is driven to improve patient safety, I thought this important to consider for those in professional healthcare settings:

Despite the potential for health information technology to improve patient outcomes, adverse events associated with the use of health IT can cause extensive harm and are encountered across all healthcare settings.

That’s the finding of a new analysis of electronic health record-related harm in cases submitted to a large database of malpractice suits and claims maintained by CRICO, an evidence-based risk management group of companies owned by the Harvard medical community.

Researchers identified 248 malpractice cases showing serious unintended consequences from the use of EHRs, representing less than 1 percent of all cases in the database. Of cases with causes related to EHRs, 80 percent involved moderate or severe harm. EHR errors were found to occur more frequently in ambulatory settings than in inpatient settings. Although ambulatory care accounted for more than half of the cases, deaths were more likely to occur in inpatient settings.

Read the full article on Health Data Management’s website!


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Report of an Expert Panel Convened by the National Patient Safety Foundation

to-err-is-human-update

In order to continue the growth of healthcare simulation utilization, our community must further connect with resources from Patient Safety organizations, like the NPSF. This powerful organization just released a report by an expert panel discussion assessing the state of healthcare on the 15th anniversary of “To err is human” — a critical report that outlined the number of patient deaths attributed to medical error. The number has since grown to as many as 440,000 patients a year in the US alone! How can we better connect healthcare simulation learning opportunities to better patient outcomes?

About the report:

Fifteen years after the Institute of Medicine brought public attention to the issue of medical errors and adverse events, patient safety concerns remain a serious public health issue that must be tackled with a more pervasive response.

With a grant from AIG, the National Patient Safety Foundation (NPSF) convened an expert panel in February 2015 to assess the state of the patient safety field and set the stage for the next 15 years of work.

The resulting report calls for the establishment of a total systems approach and a culture of safety, and calls for action by government, regulators, health professionals, and others to place higher priority on patient safety science and implementation.

The report makes eight recommendations:

  1. Ensure that leaders establish and sustain a safety culture
  2. Create centralized and coordinated oversight of patient safety
  3. Create a common set of safety metrics that reflect meaningful outcomes
  4. Increase funding for research in patient safety and implementation science
  5. Address safety across the entire care continuum
  6. Support the health care workforce
  7. Partner with patients and families for the safest care
  8. Ensure that technology is safe and optimized to improve patient safety

Download the full report for free at NPSF.org!

MERCI ‘Trains the Trainer’ to Reduce Medical Error Through Simulab and Northwestern University Feinberg School of Medicine Partnership

merci

MERCI ‘Trains the Trainer’ to Reduce Medical Error through Northwestern University Feinberg School of Medicine Collaboration

Recently I learned about MERCI (Medical Error Reduction and Certification, Inc.), which rolls out of Simulab Corporation. MERCI has joined forces with Northwestern University’s Feinberg School of Medicine to deliver turnkey training programs that have been proven to reduce medical errors. Northwestern has completed extensive research work using CentraLineMan and other Simulab trainers to reduce mechanical errors and infections. Watch our CentraLineMan video demonstration and on-site interview with Dr. Jeffrey Barsuk, who also touches on his research entitled “Cost Savings From Reduced Catheter-Related Bloodstream Infection After Simulation-Based Education for Residents in a Medical Intensive Care Unit”.

About MERCI:

MERCI provides turn-key patient safety training programs designed specifically to serve hospitals with goals of reducing procedural medical errors and improving patient care. MERCI uses the Train-the-Trainer programs that have been developed and validated by Northwestern University’s Feinberg School of Medicine to not only reduce medical errors but to also create a net savings to the hospital.

MERCI provides:

  • On-site validated turnkey training program implementation for system-wide standardization of training.
  • On-site in-service and auditing services to reinforce performance standards and verify compliance.
  • Self-funded training programs that pay for themselves with cost savings through error reduction.

MERCI Satisfies all Patient Safety Advocates:

  • Medicine: Procedural training programs proven to improve patient outcomes by reducing mechanical errors and hospital acquired infections.
  • Risk: Validated programs proven to reduce the rate of adverse events and improve the overall culture of safety.
  • Finance: Training programs that show immediate return on investment by saving the hospital more than the cost of the training program by reducing expenses in three areas: non-reimbursed events, Medicare safety rating penalties, and litigation expenses.

Very excited to watch and learn more about how this new venture will reduce adverse events and costs through evidence-based training programs!

Determine the potential for adverse event reduction and the return on investment, learn more at MerciProgram.com


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Medical Student Speaks Up and Saves a Life — But Not Without Persistence

medical errors

Recently read this article on KevinMD.com about a 3rd year medical student risking his ego and speaking up for a patient he felt was in danger. While this story had a happy ending, you can see how much internal struggle Andrew goes through to request and then finally demand help. With an average of 1,000 patients dying a day due to medical error we have continue to ask why new medical and healthcare professionals are being trained into a system that has serious consequences for “wasting staff time” against saving patient’s lives.

Consider this story from 3rd Year Medical Student Andrew Ho:

As a third-year medical student, we are considered to be the bottom of the totem pole in the hospital. After spending the first two years studying for our Step 1 boards, the only clinical medicine we know comes from what we have read and heard about in books and lectures. Our questions are frequently met with laughter or are berated for lacking common sense. And in the fast paced world of the ED, nobody has time to answer stupid questions. “His nurse probably knew he had a head laceration,” I reasoned . “There’s no need to alert anybody. He’s not even my patient. The ED staff is more than capable of handling this.”

A minute passed. And then another. Nobody came by to see this patient, who continued to bleed. I hesitated against speaking up, since we were in the middle of a trauma. But I couldn’t wait any longer. I asked an ED nurse if he was her patient. “No,” she said before hurrying off. I told another nurse that a man was actively bleeding and he said, “Go get his nurse!” After a few more failed attempts, I had had enough and pulled aside my resident. “I think this man has been bleeding profusely for some time. What should we do?” His eyes widened as he saw the amount of blood that had soaked into the sheets. He reached for a pair of gloves and told me, “Get a suture kit, now!”

I hurried off to the supply closet and came back with a bunch of supplies. The patient was now writhing in pain as we dug around with our fingers inside his wound, trying to locate the bleeding vessel. We liberally injected lidocaine before exploring deeper with pickups and clamps. I tried to dab away the blood so that we could see into the laceration, but blood instantly filled the cavity. We couldn’t localize the source of the bleeding and our attempts to blindly clamp the vessel were met with frustration. Anytime we thought we stopped the bleeding, blood would spontaneously squirt out, like water spewing from a compressed hose. When the blood splashed up against our glasses, my resident and I looked at each other and knew we needed more help.

We wheeled the stretcher out of the back corner and into the trauma bay where we applied Yankauer suction into the wound. This helped us visualize the lacerated artery quickly. We clamped the vessel to stop the bleeding and tied it off with sutures. Given the amount of time he went unnoticed, we estimated that that patient’s estimated blood loss was anywhere from 500-1000 mL and gave him IV fluids to help replenish his intravascular volume. When the chaos had settled, a very surprised ED attending entered the bay. “He was playing on his cell phone just a few minutes ago!” she exclaimed. She thanked us for our work and my resident commended me with a quickly muttered, “Good job.”

A quickly muttered “good job” and no department follow-up or debrief? This was one time a medical student stood up but what about the next time his counter-part remains silent? Check out yesterday’s story on how “silence kills” in healthcare and learn about a book called “Beyond the Checklist” that shows us how we can fix this systemic problem.

Read the full story on KevinMD.com