Patient safety - Protect yourself from medical errors

1. Medicalerrorscanbeanightmare,bothforpatientsandfortheirdoctors,but thisisatopicweprefertosweepunderthecarpet,becauseitcanbeso emotionallycharged.However,ifweneedtotacklethem,weneedtodiscuss themopenly,whichiswhythisbookissotimely. WWhoshouldreadthisbook?It'sbeenwrittenforhealthcareprofessionalsas wellaspatients,isbookisapotentmixwithverydistinctiveingredients becauseitspeakstoeveryoneinthehealthcaresystem -doctors,nurses, pharmacists,pharmaceuticalcompanies,insurersandpatients.ereason forthisdeliberatemulti-prongedapproachisbecausehealthcareisnot deliveredinsilos.Patientsafetyaﬀectsallofus,andweallneedtocontribute tothesolutionaswell! IIfyouareapatient,pleasereaditbeforeyougotothedoctor.Ifyouarea doctor,pleasereaditbeforeyouseeyournextpatient! Author:DrAniruddhaMalpani,MD MRP:Rs.300/- www.healthlibrary.com Hispassionispatientempowerment;andhebelievesthatpatientsarethe largestuntappedhealthcareresource;andthatweneedtousepatientpower tohealoursickhealthcaresystem. DrAniruddhaMalpaniisanIVFspecialistwhorunsthe world’slargestfreepatienteducationlibrary,HELP,at www.healthlibrary.com. Hehasauthoredmanybooks,including:HowtoGetthe BestMedicalCare;SuccessfulMedicalPractice;Patient Advocacy-GivingVoicetoPatients;andDecodingMedical Gobbledygook.

2. Patient Safety – Protect Yourself from Medical Errors Dr Aniruddha Malpani, MD

3. 2 All rights reserved. No parts of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of the author. © Dr Aniruddha Malpani Published by Dr Aniruddha Malpani aniruddha.malpani@gmail.com Powered by Pothi.com http://pothi.com Price: Rs 300 HELP – Health Education Library for People Ashish, Tardeo, Mumbai: 400034, India Tel. No: 65952393/65952394 www.healthlibrary.com Helping patients to talk to doctors! The website for this book is www.safetyforpatients.in Cartoon by Sidney Harris – ScienceCartoonsPlus.com Cartoons by Dr Hemant Morparia – Dr Hemant Morparia Printed in India

4. 3 This book is dedicated to all patients and doctors in India – both present and future – with the hope that we can work together to keep patients safe !

6. 5 Contributors Dinesh Chindarkar holds a degree in Life Sciences & Pharmacy. He specializes in marketing management and has an advanced certification in Digital Marketing. He is the co-founder of MediaMedicCommunications–ahealthbrandcommunication&HealthPRfirm.Hiscompany MediaMedic is a part of the GLobalHealthPR group which organized the 1st International Healthcare Social Media Summit in Washington DC. He has also co-authored the The Global Guide to Pharma Marketing Codes. His email is dinchin@yahoo.com Helen Osborne M.Ed., OTR/L is a health literacy expert who helps others communicate health information in ways that patients, caregivers, and the public can understand. Helen is president of Health Literacy Consulting, founder of Health Literacy Month, and hostess of the podcast series, “Health Literacy Out Loud.” Helen is also author of the award-winning book, “Health Literacy from A to Z: Practical Ways to Communicate Your Health Message, Second Edition”. Her website is www.healthliteracy.com and her email is helen@healthliteracy.com Reshma Ansari is a senior Hospital and Healthcare management professional. She is Manager, Quality and Patient Safety at Breach Candy Hospital Trust, Mumbai, one of India’s leading hospitals. She is an empanelled NABH Assessor. Her email is ansarireshma@rediffmail.com Dr Anupama Shetty is a PhD student at the Tata Institute of Social Sciences, Mumbai. She earned her MBBS in 1995 and Masters in Hospital administration from TISS in 2007. Her work revolves around studying strategic change in healthcare organizations, accreditation, and the culture of safety, with a focus on complex adaptive systems. She has been granted an ICSSR fellowship in the course of her PhD. Her email id is mha2007@gmail.com Salil Kallianpur is a senior executive in the pharmaceutical industry. He is an avid observer of the health care industry and comments on the intersection of strategy and development through his blog and twitter accounts. The views expressed here are his own and do not reflect the views of his employer. He tweets at @salilkallianpur and can be reached at skallianpur@ gmail.com and on LinkedIn at www.linkedin.com/salilkallianpur. Dr Reshma Nayak is the business head and editor of thehealthsite.com , a part of the Zee media group. It is currently the most popular Indian health website in the country. She is a dentist by profession, and a digital enthusiast by choice. Understanding online audiences and engaging with them is what she enjoys. Her email is reshma@corp.india.com Dr Nikhil Datar is a senior Gynaecologist practicing in Mumbai. He is also a renowned health activist and has fought legal battles on health rights issues. He is a prolific writer on various medical and health related subjects. He is the Founder President of Patient Safety Alliance at www.patientsafetyalliance.in which works to empower patients and health care professionals to prevent medical errors.

8. 7 Chapters The night I nearly killed my patient 9 Background – Setting the Stage 1. Why medical errors are so common- And why we don’t talk about them 13 2. When, why and how things can go wrong –The anatomy of medical errors 17 Patient Safety from the Patient’s Perspective 3. How patient empowerment improves patient safety- Knowledge is power! 22 4. Misdiagnosis as a cause for medical errors – and how to prevent them 27 5. How overdiagnosis and overtreatment can lead to medical errors- and how to protect yourself 33 6. Social media and the internet for reducing medical errors - how the wisdom of the crowds can improve patient safety 38 7. Health literacy is the safety shield against errors - How can you use it? 40 8. Patient advocates- Advocating for safety 43 9. How hospitals can be made safer- How to make sure “never “ events never occur 46 10. Protecting yourself from medical billing errors- The need for vigilance 50 11. Did the doctor make a mistake? Or was it negligence? 52 Patient Safety from the Professional and Clinical Perspective 12. The Science of patient safety – Mistake-proofing medical care 58 13. Designing for safety – Moving from Swiss cheeses to Swiss watches 63 14. How Communication helps to keep patients safe - the importance of teamwork 69 15. How a strong patient-doctor relationship enhances patient safety- working together to prevent errors 72 16. Managing mistakes in medicine – A guide for doctors 75 17. Risk management for doctors – When things go wrong 81 18. Protecting the impaired physician – why we need to break the conspiracy of silence 85 19. The nurse’s role in promoting patient safety - Checking the “five rights” 87

9. Patient Safety – Protect Yourself from Medical Errors 8 20. Reporting errors so we can learn from them- How to stop good people from making bad mistakes 90 21. Errors in IVF- And how we avoid them 93 22. Developing a culture of safety in hospitals- Humans are not perfect, so improve the system 96 23. The role of a hospital patient safety officer- And how she can help to reduce medical errors 101 24. How can hospital management engage with doctors? Convincing doctors to commit to patient safety 104 25. A simple, low-cost method to prevent errors in hospitals- The whiteboard solution 107 Patient Safety from the System Perspective 26. Keeping patients safe in India - What policymakers can do 111 27. How medical fraud and corruption harm patients- And why it is rampant in India 115 28. How health insurers can keep patients safe- Creating a financial safety net 117 29. Drug safety: A huge challenge and an even bigger opportunity- How to mitigate the risks 119 30. Pharmaceutical companies as partners in patient safety – Time to learn from the West 125 31. How pharma can leverage technology to make care safer- A wide range of solutions 128 32. Medical device safety- The current state of affairs 130 33. Digital health can make medical care safer- all about EHRs and apps 134 34. How media can bridge the doctor-patient gap- Patient education is the holy grail 138 35. The Patient Safety Alliance - Keeping patients in India safe 140 Final Thoughts 36. The aftermath: The need for open disclosure to allow healing 143 37. The night I nearly killed my patient—redux 148 38. A new beginning- Challenges and opportunities 150 If you’d like to find out more 151

10. 9 The night I nearly killed my patient Success does not consist in never making mistakes, but in never making the same one a second time. George Bernard Shaw Many moons ago, I was working in King Edward Memorial (KEM) Hospital, as a junior resident house surgeon in the obstetrics and gynecology (OB/GYN) department. KEM is a busy public hospital in Mumbai, and we supervised over 7000 births every year. Since we were a renowned teaching hospital, plenty of serious patients were referred to us for emergency treatment. Because there was so much work, we were always sleep deprived, but this was considered to be par for the course. Our seniors felt that we had to be taught how to keep midnight vigils – a traditional occupational hazard for obstetricians. We got to treat lots of complications during labor, and this hands-on experience was considered to be invaluable. The patient The teaching program was highly unstructured, and we followed the traditional “see one, do one, teach one” approach. During night hours, the senior staff members (lecturers and professors) in the unit were never in the hospital premises, and the unit was managed by a Registrar, who was 2 years senior to me. Along with my senior house surgeon and the registrar, I was responsible for overseeing the care of all obstetric patients who were admitted from 4 pm to 8 am. I had been in hospital for 3 days, since we had quite a few sick patients admitted under our care. As the junior-most doctor on the team, I was responsible for doing all the scut work and monitoring the patients. I was on night duty when a 28 year old primigravida was referred to us from a private hospital. She was in advanced labor and had severe preeclampsia (pregnancy induced hypertension or PIH). The registrar and the senior house surgeon did the emergency caesarean section, and I took her blood to the pathology lab for testing. After the surgery, when the patient was stabilized and the baby safely delivered, the registrar and senior house surgeon went off to bed, leaving me to monitor her in the ward with the instruction that I was supposed to give her enough IV (intravenous) fluids to make sure her blood pressure (BP) remained normal. The error She was tired and drowsy after her surgery, and so was I. I religiously checked her vital signs, and when I noticed that her blood pressure was low, I kept on pumping in IV fluids, to keep it in the normal range. Her BP kept on dropping, so I ordered the nurse on duty to pour in large quantities of IV fluids to help her maintain her BP. I was so focused on making sure her BP was normal, that I did not realize that all the extra fluid we were pumping into

11. Patient Safety – Protect Yourself from Medical Errors 10 her was leaking out of her blood vessels and getting trapped in her subcutaneous tissues, causing her to develop systemic edema. I was basically following the orders given to me, and wasn’t experienced enough to be aware of the risks of a fluid overload in a patient with PIH. By the time morning came around and the senior houseman came to check on me, she had received over 12 liters of IV fluids in 3 hours in my attempt to keep her BP in the normal range. Her entire body had become grotesquely swollen and distended, and she was having difficulty breathing because of the accumulation of fluid in her larynx. We had to do an emergency tracheostomy and transfer to the ICCU and put her on a ventilator to stabilize her. She had a stormy course, but finally went home after 2 weeks. I still have nightmares about her, and it was only later I found out that patients with PIH are known to have leaky blood vessels, as a result of which the IV fluid which I was giving her was leaving her circulatory system and getting trapped in her subcutaneous tissues. I was mercilessly and publicly berated for my incompetence by the senior house surgeon, registrar and professor. I was very vulnerable, and was punished for my transgression by being forced to monitor patients every night for the remaining 3 months of my residency. I felt that I deserved the punishment which was meted out to me, and took it quietly. I kicked myself many times for not knowing more about how to manage a patient with severe PIH, and was extremely grateful that the patient had survived in spite of my ignorance. Making matters worse I was ostracized by my colleagues, and treated like a pariah for having nearly caused a patient to die, which would have been a blot on the hospital’s reputation. There was no one I could talk to about what had happened and why; and I had to bottle up my mixed emotions (of fear, guilt, shame, anger, embarrassment and humiliation) throughout the remainder of my residency. I needed emotional support and professional reaffirmation from my seniors and teachers that I was still a good doctor, inspite of my mistake. However, I was abandoned and left to fend for myself. The moment my post was over, I moved to another hospital, to try to erase these unhappy memories. Most doctors have had a similar experience, where they have made a mistake that caused harm to their patient. This is one of medicine’s dirty dark secrets which doctors don’t discuss in public. The purpose of this book is to change this approach, because unless we start talking about medical errors, we will never be able to prevent them. There’s a lot that could have been done to protect my patient, at many different levels; and this is what we need to focus on. The reason for the error was not just my ignorance; it was also the fact that I wasn’t supervised properly. In addition, the infrastructure in the hospital wasn’t adequate to care for such a sick patient. Things would never have come to this pass if there had been proper protocols for the management of PIH. These patients are very ill, and should ideally have been monitored in an ICU, where close 24-hour supervision is being

12. The night I nearly killed my patient 11 provided by experienced clinicians. She should never have been left on a bed in the ward, under the care of a green and inexperienced house surgeon, no matter how well meaning I may have been. How can we change the system, so that patients are protected from medical error? This is the question this book will try to answer.

13. 12 Background – Setting the Stage Medical errors are the diseases of the healthcare delivery system. However, a medical error does not always mean there was negligence, and not all errors cause harm. We start from the basics, by defining and classifying the various types of medical errors. We then take a look at why medical errors occur; and how we can learn from them, so we can prevent them in the future.

14. 13 1 Why medical errors are so common- And why we don’t talk about them To make no mistakes is not in the power of man; but from their errors and mistakes, the wise and good learn wisdom for the future. Plutarch In a perfect world, physicians would never get tired and never get stymied by a patient with an unusual symptom. They wouldn’t have to hand-off their patients to the doctor working the next shift and nurses would communicate instructions to each other with perfect clarity. Sadly, the real world is far more error-prone, and while most medical errors are small harmless slip-ups, occasionally they balloon into full-blown tragedies. While patients know that doctors will not always be able to cure them, they do expect that they will at least not be harmed; and that the treatment will not be worse than the disease. Medical errors are the dark side of medical progress, a consequence of the ever-increasing complexity of modern medicine. However, there’s a lot we can do to reduce their frequency and impact, and there are plenty of success stories we can learn from. Oneofthereasonsthefieldofpatientsafetyisvexingisthatittakesauniquelyinterdisciplinary effort to protect patients from harm -one in which hospital CEOs, doctors,nurses, pharmacists, managers, administrators and patients forge new relationships and combine their strengths to overcome weaknesses. Definitions In the early years of the safety field, the target was errors, and we focused on measuring and decreasing error rates. This model has given way to a new focus on measuring and attacking “harm” or “adverse events” where harm is the “outcome” and errors are the “process.”

15. Patient Safety – Protect Yourself from Medical Errors 14 After all, patients, quite naturally, care more about what happens to them than whether their doctor or nurse made a mistake. We need to differentiate complications (adverse events that arise from the underlying disease) from medical harm (unintended injury caused by medical care). Not all adverse events are preventable, and those that are, usually involve errors. An error is “an act of commission (doing something wrong) or omission (failing to do the right thing) which may lead to or which causes an undesirable outcome.” Many errors do not result in adverse events and these are called ‘near misses’ or ‘close calls’. When the error is a result of care that falls below a professional standard of care, it’s called negligence. ** Harm-Any physical or psychological injury or damage to the health of a person, either temporary or permanent. Harm is usually classified as no harm, low harm, moderate harm, severe harm or death. ** Nearmiss-Anypatientsafetyincidentthathadthepotentialtocauseharmbutwasprevented, resulting in ‘no harm’ ** Adverse event or error- An event involving unintended harm to a patient that resulted from medical care. Traditionally, the term used for an adverse event was ‘iatrogenesis”. ** Preventable adverse event- An adverse event due to error. Harm is caused either by a wrong or inappropriate action (‘error of commission’) or by failure to do the right thing (‘error of omission’). ** Patient safety incident- Any unintended or unexpected incident that could have harmed or did harm the patient. This includes ‘near misses’. The term ‘patient safety incident’ is preferred to “error”, as the latter has a more negative connotation. ** Patient safety- Freedom from accidental injury. We need to establish systems to decrease errors, and to intercept them when they occur. ** Hazardous condition- Any set of circumstances which significantly increases the likelihood of an error. Venn diagram depicting the relationship between errors, complications and negligence.

16. Why medical errors are so common- And why we don’t talk about them 15 Learning from our mistakes We need to openly acknowledge that errors are an integral part of the human experience. This will allow us to radically transform our approach to medical error. After all, one of the best ways to improve oneself is to recognize mistakes and to learn from them. The same strategy applies to providing the best patient care possible, and we need to treat medical errors as a treasure, rather than try to hide them, or shy away from discussing them. Medical care can be a double-edged sword. While doctors can save lives, they can also end up harming patients. This unnerving fact that healthcare can harm us as well as heal us is the reason why patient safety lies at the core of healthcare quality. While effectiveness, access to care, timeliness and the other dimensions of quality are all very important, safety is always the topmost priority. At least 1 in 10 hospital admissions are marred by an adverse event, and about half of these are preventable. About one-third of these adverse events cause true patient harm. The fact that the harm was not deliberate is cold comfort for the patient who was at the receiving end. Medical errors can result in permanent injury, and even death. The real tragedy is when the harm could have been prevented, but was not! We cannot afford to turn a blind eye to these errors, or adopt a “chalta hai” attitude. While it’s easy to look for a scapegoat and blame the doctor and hospital when something goes wrong, the truth is that medical errors do not necessarily occur because doctors are callous or careless. The current healthcare system is complex and overloaded; it means that the successful outcome of a medical procedure depends on a range of factors, and not just the competence of a particular doctor! With so many variables and healthcare personnel (doctors, nurses, pharmacists, lab technicians, dieticians etc) involved in the care of one individual, it’s no surprise that patient safety can sometimes become a casualty. Problems can snowball, and the term “toxic cascades” describes how small errors which trickle by unnoticed can eventually add up to become torrents. What is the difference between patient safety and quality? Patient safety is an important element of an effective, efficient health care system where quality prevails. These two factors go hand-in-hand; there can never be any quality without safety! Here’s how you can break it down: ** Safety has to do with lack of harm. Quality has to do with efficient, effective, purposeful care that gets the job done at the right time. ** Safety focuses on avoiding bad events. Quality focuses on doing things well. ** Safety makes it less likely that mistakes happen. Quality raises the ceiling so the overall care experience is a better one. The ‘patient safety first’ culture needs to become part of the DNA of the healthcare system. This means committing to safety at all levels of the health facility, right from the frontline staff to doctors and nurses as well as the board of directors.

17. Patient Safety – Protect Yourself from Medical Errors 16 Medical errors from the doctor’s perspective There are times when we doctors forget about the real identities of the people we address as “patients.” We talk about them with clinical detachment, often presenting them as “cases” to colleagues. We forget that they, like us, are made of flesh and blood, have families, jobs and responsibilities, dreams, aspirations and the desire to get healthy and move on with their lives ! Medical errors are not mere statistics. When we encounter an error, we should put ourselves in our patients’ shoes and learn to ask, “How do I prevent this from happening again?” Behind each event there’s a real-life story about patients and their loved ones. Some patients who have been harmed by medical errors may take legal action against the doctors who provided them care, and there’s a separate story about the doctors and nurses whose lives and careers are torn apart, because of faulty systems and processes. Doctors too will become patients one day. We will fall ill, and will need consultation, diagnosis and medical care, just as every other mortal does. As doctors, we know a lot about everything that can go wrong, and this can create a lot of anxiety, nervousness and fear in our hearts. It’s probably only when we are at the receiving end that we realize how important patient safety is. Although human error will always remain an ‘uncontrollable’ variable in the delivery of healthcare, there’s a lot we can do to minimize errors.

18. 17 2 When, why and how things can go wrong –The anatomy of medical errors Amid many possibilities of error, it would be strange indeed to be always right. Peter Latham A complex affair Providing medical care is a complicated affair. Given the massive number of variables involved (the ability of the patient to provide an accurate history; the expertise of the doctor; the number of health care professionals involved in providing medical care; the difficulty in interpreting test results; and the unpredictable natural history of an illness), it’s hardly surprising that things can go wrong. Anyone who has donned a white coat will tell you what a tough job it is to dedicate your life to the care of anxious patients, especially uneducated ones, or those who do not speak the same language! A good definition of medical error was provided by Dr. James Reason, a Professor of Psychology whodescribesmedicalerroras –“circumstancesinwhichplannedactionsfailtoachievethedesired outcome”. However, the matter is complicated by the fact that there is no clear-cut definition of what constitutes “gross negligence”, “medical negligence”, “error of judgment”, “accident”, “neglect” or plain “recklessness”! To err is human Human error implies that if the medical team member had acted differently, the injury caused to the patient could have been prevented. We all make errors – after all, that’s what makes

19. Patient Safety – Protect Yourself from Medical Errors 18 us human! Jens Rasmussen has suggested that errors occurred due to deficiencies in either one of the following: ** Skills (e.g. asking an inexperienced doctor to perform a laparotomy without supervision); ** Observation of rules (e.g. not washing hands before performing a procedure); or ** Knowledge (e.g. being unaware that gentamicin levels in the blood need to be checked). The truth is that medical errors can occur regardless of a doctor’s vigilance, good intentions, skill, experience or expertise. This is because medical care is a complicated system, and complex systems do fail unpredictably. What we need to do is to work on the system, so that it becomes easier for doctors and other healthcare professionals to go about discharging their duties in a more efficient, error-free manner. The modern approach to patient safety hinges on “systems thinking”- recognition that most errors are made by competent, careful, and caring providers; and that preventing these errors often involves embedding providers in a system that anticipates glitches and catches them before they do harm. James Reason’s Swiss cheese model for medical error The “Swiss cheese’ model James Reason, an eminent psychologist, developed the ‘Swiss cheese’ model to explain the multiple factors associated with errors. A wide range of defenses, barriers and safeguards exist to protect patients from hazards. These include basic tools such as alarms on syringe pumps; all the way to sophisticated human error trapping systems, such as anesthetists who check that the surgeon has done a thorough pre-operative work-up of the patient before bringing him to the Operating Room. However, these defenses can be breached, like the holes in slices of Swiss cheese. However, unlike holes in the cheese, these gaps are continually opening, shutting and shifting their location.

20. When, why and how things can go wrong –The anatomy of medical errors 19 The presence of holes in any one ‘slice’ does not normally cause a bad outcome. Error happens only when the holes in many layers momentarily line up, bringing hazards into damaging contact with patients. This means that medical error is the result of “system flaws, not character flaws”; and we can reduce human errors by “inserting additional layers of protective cheese into the system”. Types of errors This is the dominant model for understanding the relationship between active (“sharp end”) errors and latent (“blunt end”) errors. ** Latent errors- These are the hidden root causes in the system that make active errors more likely to happen – for example, poorly designed medical records, making it easy for clinicians to misunderstand reports; or inadequate staffing, making people “rush” or routinely “multi- task”. If an individual errs, in a sense she has been set up to fail by her environment. As Don Berwick, President and CEO of the Institute for Healthcare Improvement, has said “every system is perfectly designed to achieve exactly the results it gets.” These defects are difficult to measure because they are hidden, and may exist for years before they are detected. ** Active errors- These occur at the level of the healthcare provider – the frontline staff that actually delivers the services, and can cause harm. These are what we think of when we think of error, due to the focus on individual acts in medicine. Active errors can take the form of slips (doing a familiar action in the wrong way, like pouring salt instead of cream into coffee), lapses (failures of memory such that planned actions do not happen), and mistakes (errors in reasoning that lead to wrong choices). They are easier to measure because the negative outcome is much more apparent – for example, the nurse injects the wrong medication; or the doctor amputates the wrong leg.

21. Patient Safety – Protect Yourself from Medical Errors 20 Types of Medical Errors A “safety culture” system proactively scans for latent errors all the time, and retroactively looks for latent errors when an active error has occurred. The question should not be – “Who caused the error”, but “What caused the error?” Bad outcomes, just like good outcomes, are a team effort. How can we make the system safer? Here are some basic principles. ** Automate when appropriate ** Standardize – reduce reliance on memory ** Use checklists & standard operating procedures (SOPs) ** Simplify by reducing the number of steps and handoffs ** Add redundancy (double checks) for high-risk processes to create a safety net ** Stress-test the system, and try to break it, to find out the “failure points” so that these can be reduced and removed ** Respect the front-line staff, who are the real-life field experts, and ask them what can be done to help them do their work safely There is a natural tendency for things to go wrong. Safety is a dynamic non-event, and we have to work very hard to ensure nothing bad will happen. Well designed systems can help us to achieve this goal.

22. 21 Patient Safety from the Patient’s Perspective The key to patient safety lies in patient empowerment, and there’s a lot that patients can do to protect themselves from medical errors. Patients can use Information Therapy to reduce diagnostic errors; and defend themselves from overtesting and overtreatment. Health literacy is an important safety shield against errors, and patients can use social media to tap into the wisdom of the crowds. Hospitals can be dangerous places, and patients need to use checklists and patient advocates to keep themselves safe when they are hospitalized. And if an error does occur, what steps do you need to take to prevent a bad situation from becoming worse?

23. 22 3 How patient empowerment improves patient safety- Knowledge is power! Smart people learn from their mistakes. But the real sharp ones learn from the mistakes of others. Brandon Mull When we think of medical errors, we think about the mistakes which doctors and nurses make when taking care of patients. However it is not uncommon for errors to be caused by clueless patients and poorly informed care givers as well. The first conclusion most people jump to when a medical error occurs is – It was the doctor’s fault! Patients still think of themselves as being passive recipients of medical care who are at their doctor’s mercy. However, you need to take an active role in your medical treatment, and behave as an enlightened partner - after all , your doctor is not a veterinarian ! Patients can be the first line of defense against errors, and there’s a lot you can do to protect yourself. Patient safety is not just the doctor’s responsibility – it’s the patient’s as well. Patients must play an active role in preventing medical mistakes. One of the commonest mistakes patients make is that they leave everything upto their doctor. This kind of passive approach may make sense during an emergency, but is completely flawed for most elective medical treatment, and can lead to disaster if you are unlucky enough to end up in the hands of an incompetent doctor.

24. How patient empowerment improves patient safety- Knowledge is power! 23 The empowered patient An empowered patient assumes responsibility for managing her health, and this reduces the risk for errors. For example, she will call the clinic and make sure that she gets the results of the lab tests her doctor has ordered, rather than wait passively for the clinic to phone her! Patients today want to exercise the power of choice when it comes to deciding the medical care that is being provided and the manner in which it is provided. When patients actively participate in the treatment plan because they have crafted it in partnership with their doctor, they are much more motivated in complying with the doctor’s advice and this helps reduce the risk for slips and mistakes. An empowered patient is one who: ** Assumes responsibility-You know your body better than anyone else and this makes it important for you to refer to all the resources you can lay your hands on, ranging from people to the printed word, to make an informed and critically evaluated decision. ** Collaborates-Know that this is a challenging journey and that you will need help to traverse this path. Support can be invaluable, so please be gracious in accepting it. Co-operate fully with the medical staff during your diagnosis and treatment processes. ** Gathersevidence-Leavenostoneunturnedwhenitcomestolearningmoreaboutyourillness and treatment options. Check with other patients, make observations, record symptoms, take family histories, participate in clinical research, and use the internet to become well- informed. ** Stays safe- Be vigilant; do not let your guard down. Medical errors can occur at the best of establishments, and you need to ensure that you don’t become the victim of those errors. ** Appoints a patient advocate-If you don’t feel confident enough about handling everything yourself, seek support from a more knowledgeable and resourceful patient-advocate, who will be able to work the system in your favor. They can easily achieve what patients and their families sometimes can’t – get prompt and safe medical care. ** Is firm-Once you have made prudent choices, stand by them and you will find that you are more confident and in control ** Organizes and updates her medical records. http://www.myphr.com/ from the American Health Information Management Association (AHIMA) is a comprehensive resource for anyone interested in creating their own personal health record (PHR). Sadly, most patients are still very passive, and are happy to leave everything upto the doctor. They are scared to ask questions, because they underestimate their ability to make sense of medical care. This can be dangerous, especially when things aren’t going well, and you need to learn to speak up by being aware and well-informed. After all, if you don’t look after yourself, then who will? Do your homework – become an expert patient! Before starting your research, you first need to obtain basic information about your medical problem. What is your diagnosis? Your doctor can provide you with this, along with explaining what alternative terms can be used to describe your condition; this helps you gain

25. Patient Safety – Protect Yourself from Medical Errors 24 the fundamental knowledge to begin your research. Make sure you get the spellings right- write them down! Of course, for some complex medical problems, it may not be possible to even come to a diagnosis, but such cases are rare. You need to spend a little time thinking about exactly what kind of questions you want answered from your online research: remember, GIGO (garbage in, garbage out). The more precise your questions, the easier it will be to find answers to them! Thus, it would be counterproductive to look for ‘everything about diabetes’. A more realistic query could be: ‘Is it possible for a diabetic to control his blood sugar levels without medications?’ Or you might want to search for newer treatment options, such as pancreatic transplants, or look for a world-renowned expert who specializes in treating diabetic complications affecting the eye. Doing a Google search can leave you lost and even more confused than when you started, because you can get millions of results, many of which are outdated and unreliable! To make sure you don’t get misled, you need to evaluate the credibility of the sites you visit. To learn how to do this, watch the National Library of Medicine’s (NLM’s) short video on ‘Evaluating Health Information’ at: http://www.nlm.nih.gov/medlineplus/webeval/webeval.html Researching your problem is not like a single path that proceeds straight from the initial question to the final answer; it is actually more like a cycle. Initial questions lead to references which lead to other papers, which, in turn, again, lead to more references, and more questions; and as the process continues, you get wiser and closer to the answers. Eventually, you will zero-in on the information that is the most valuable to you. This process cannot usually be completed in a single day. The research cycle may even take you to a wide range of medical databases, doctors, and medical libraries. It is helpful to pretend that that you are the ace detective Sherlock Holmes, looking for a vital clue! A single site will not provide you with all the information you need. Thus, while the HELP website at http://www.healthlibrary.com will provide you with lots of information about your illness (in easy-to-understand terms), if you want to connect with other patients and learn from their experiences, you will need to go to online Bulletin Boards, patient blogs and Community Forums. Stories written by other patients will help you identify the potential danger zones and red flags, so you are better equipped to protect yourself from these hazards. It is important to determine beforehand how much information you actually need to make yourself comfortable with your diagnosis and treatment options. Some patients are infovores, and need as much information as they can possibly gather! Others are happier with less information because they prefer leaving technical minutiae upto their doctor. Some patients prefer to hear only the good news, while others want the whole picture, including the negative possibilities. Form a partnership with your doctor Again, let your doctor know what precisely your needs are. He can provide you with printed matter or other sources of information, as well as point you towards other resources that can

26. How patient empowerment improves patient safety- Knowledge is power! 25 help you gather whatever information you find necessary. You need to seek your doctor’s help to make sense of the wealth of medical information available to you. He can explain to you how the information you have unearthed applies to you as an individual. You need to collaborate with your doctor, but to be treated as a well-informed partner, you need to do your homework thoroughly first! Most good doctors would be happy to assist and answer your queries, but the reality is they are often very busy. If you do your research, you can ask them intelligent and focused questions. This saves them time, and will help you to earn their respect as well. Information Therapy can be Powerful Medicine, and can help you by: 1. Promoting SelfCare- So you can do as much for yourself as you can, without being overly dependent upon your doctor. 2. Helping you with Evidence-Based Guidelines- So that you can ask for the right medical treatment that you need - no more and no less. 3. Helping you with Veto Power- So you can say No to medical care you don’t need, thus preventing over-testing and unnecessary surgery. You can read my book, Using Information Therapy to Put Patients First, at http://www.slideshare.net/malpani/using-information-therapy-2014-upload An empowered patient is the CEO of her health team Here are a few things that a well-informed, empowered patient can say: ** I feel comfortable with each of my doctors ** I believe I’m doing everything I possibly can, to be an empowered team player ** My healthcare team is supportive of my decisions to seek a second opinion when I want to do so ** I have spoken with specialists and have conducted my own research to keep abreast of the latest information about my disease ** I source credible websites for the information I need ** I know whom to contact if I need financial help for treatment ** I get support by connecting with other patients ** I take steps to prepare for each visit- I jot down a list of questions beforehand and bring them with me ** I use a system to organize my health records ** I ask friends, family, or trusted coworkers to help out when necessary

27. Patient Safety – Protect Yourself from Medical Errors 26 Using the acronym SPEAK UP, JCAHO (the Joint Commission on Accreditation of Healthcare Organisations, USA) has developed a set of steps that patients and their families can follow to ensure that they have a positive health care experience. S: Speak up if you have questions, or if you don’t understand something; P: Pay attention to the care you are receiving, including medications and treatments. Don’t assume anything; E: Educate yourself about your diagnosis, the medical tests you are experiencing and your treatment plan; A: Ask a trusted family member or friend to advocate for you; K: Know what medications you take and why. This is especially crucial because medication errors are the most common health care error; U: Use a health care organizations that has been evaluated against current quality and safety standards; P: Participate in all decisions about your treatment.

28. 27 4 Misdiagnosis as a cause for medical errors – and how to prevent them Experience is making mistakes and learning from them. Bill Ackman Diagnosis plays a central role in medicine, and getting it right is pivotal in helping the patient to get the appropriate care. Making a diagnosis is a complex exercise, because patients don’t come with labels saying I suffer from this condition or that one. There is probably no task more challenging for a doctor than making the correct diagnosis. The doctor needs to be a detective in order to figure out what’s wrong, and it’s because there is so much that we still have to learn about the human body, that diagnosis is still a very uncertain art. It takes considerable clinical acumen to make the right diagnosis, which is why one in every ten diagnoses is wrong. Diagnostic error is the leading cause of medical malpractice claims in the US, and is estimated to cause 40,000-80,000 deaths annually. It’s because misdiagnosis can do so much harm, that we need to ensure that the diagnostic process is timely, accurate, reliable, and efficient if we want to make medical care safe. When do diagnostic errors occur? A diagnostic error occurs when either the diagnosis is wrong, missed or delayed. The cause of diagnostic error is often multi-factorial, and it could be a result of cognitive errors, which

29. Patient Safety – Protect Yourself from Medical Errors 28 are mistakes in the doctor’s thought process, perhaps because he is rushed; system errors, for example, because of a lack of communication, as a result of which an abnormal lab result is overlooked; and a combination of both. A diagnostic error is more closely associated with some specialties than others, such as radiology, geriatrics and emergency medicine. They are common in the ICU (Intensive Care Unit) as well, where patients have multiple complex problems. Interestingly, it is not only the rare disease that is the subject of diagnostic error; it is the misdiagnosis of common diseases such as heart attack, cancer and stroke which causes the most harm. Differential diagnosis Doctors are taught to follow a disciplined process in order to make the right diagnosis. This involves collecting information from the patient by taking a history, doing a clinical examination, and ordering lab tests. The clinical data then needs to be analyzed and processed. The systematic method that doctors use to come to the right diagnosis is called differential diagnosis. The doctor makes a list of possible diagnoses in order of probability, and then tests the strength of each diagnosis by asking further detailed questions, ordering more tests, or referring the patient to specialists. A differential diagnosis checklist helps physicians avoid the most common cause of diagnostic error-failure to consider the correct diagnosis as a possibility. Ideally, a number of potential diagnoses will be ruled out as the investigation progresses, and only one will remain at the end. Of course, given the uncertain nature of medicine, this is not always the case. Technology can also aid doctors to help minimize diagnostic errors. Medical digital databases like Watson @ http://www.ibm.com/smarterplanet/us/en/ibmwatson/ and Isabel @ www.isabelhealthcare.com can be utilized intelligently to boost the doctor’s diagnostic accuracy, by serving as diagnosis support systems. They do not replace the doctor, but act as a safety net by reminding him to consider all possibilities, so he does not overlook a particular disease. Why does misdiagnosis occur? Doctor Since the doctor has to make the diagnosis, there are many ways in which he can err: ** Most doctors know only the common diseases-There is more than 20,000 human diseases, and most doctors don’t know about the rare ones, which is why these are often missed. ** Different doctor skill levels-Not all doctors are alike, and while a general practitioner is well versed in common diseases, a specialist would know a lot more about the rare diseases(in his specialty). ** Doctor bias-All doctors are human and have biases. If they see a certain disease frequently, they tend to diagnose it frequently, and this might result in an error if the patient does not have that disease, but something with similar symptoms.

30. Misdiagnosis as a cause for medical errors – and how to prevent them 29 ** Saving you money-Some doctors will avoid tests, because they don’t want you to pay extra for tests which are not likely to be helpful. This works well for the majority, but can result in a misdiagnosis for the small percentage that might have a rare disease. ** Lack of time- It really is quite sad how little time a doctor will typically spend with a patient. In reality, doctors have to shoot from the hip; although they’ll hit the mark with most common diseases, they can get tricked by rarer conditions. ** Some symptoms are hard to analyze-Medicine can be complex and the human body can fool even the smartest doctors. Laboratory tests and imaging studies The various medical tests that are used to confirm or rule out diagnoses can also sometimes fail. They are useful tools, but are not perfect and the things that can go wrong are: ** Human errors- Samples could get contaminated or mixed up, or the test procedure might be done improperly-for example, if the laboratory technician is unqualified, or the lab is poorly equipped. This can be a major problem in India, where quality control is often lacking. ** False positives and false negatives- A problem with all medical tests, no matter how well they are performed, is that they may give rise to false positives and false negatives. Let me clarify. False positives are test results which are abnormal (‘positive’), even though the patient has no disease. A false positive result causes needless anxiety, and will often lead to a situation in which the patient will have to undergo even more tests to prove or disprove the previous results. Conversely, test results which are normal (‘negative’), even though the patient does have the disease are called ‘false negatives’. These results could also cause problems, because they may induce a false sense of security, thereby leading to a delayed or missed diagnosis. Most tests have a wide range of normality, and can only very rarely yield a simple ‘yes’ or ‘no’ answer as to whether a patient has a particular disease or not. ** Misinterpretation-Many tests rely on the expertise of the doctor doing them-for example, the skill of the pathologist in analyzing the tissue biopsy he receives. Errors are rare, but they can occur. Thus, errors made by radiologists in interpreting scans fall into two groups: • Perceptual errors (missing what is on the film) • Cognitive errors (seeing what’s on the film, but failing to attach significance to it)

31. Patient Safety – Protect Yourself from Medical Errors 30 The ABCs of Misdiagnosis – How patients can help their doctor to make the right diagnosis Poor quality labs The unreliability of medical tests also poses a major problem for patient safety in India today. The most obvious reason can be attributed to laboratories whose functioning is marred by poor quality control, unskilled manpower and obsolete equipment. There is little ‘policing’ or retesting; this results in subpar standards. After all, even a science graduate with a six-month diploma in laboratory technology can set up a medical lab today, if he so desires. Most people tend to rush to the nearest laboratory to get their tests done, but such haste can be a big mistake. After all, if the laboratory is not reliable, how can you trust its report? You should try and go to the best laboratory possible- your life can depend upon your test results! Patient It may seem unfair to hold a patient responsible for a wrong diagnosis, but what the patient does (or does not do) can contribute to a wrong diagnosis as well. This is how patients sometimes end up shooting themselves in the foot: ** Self diagnosis-The most likely way for a patient to contribute to a misdiagnosis is attempting to diagnose themselves, without professional medical advice. ** Not reporting symptoms-Sometimes patients don’t tell their doctor everything, either because they are embarrassed, or they feel that it’s minor, and not worth mentioning. ** Failure to perform the ordered tests-In some cases, patients don’t get diagnostic tests done, even when a doctor has ordered these. This can occur due to oversight, financial constraints, complacency, laziness or embarrassment.

32. Misdiagnosis as a cause for medical errors – and how to prevent them 31 What can patients do to reduce diagnostic error and harm? ** See a doctor- A majority of the diagnoses made by doctors are correct , and are far more likely to be accurate than your own. Never self-diagnose based on what you have read on the Internet, in books, or gathered from amateur advice. Doctors are trained to see signs that patients don’t. ** See a specialist- A trained specialist is even less likely to make a wrong diagnosis than your family doctor. ** Ask for a diagnosis- Ask your doctor to explicitly name his diagnosis. Sometimes the doctor may not be sure what the diagnosis is, and a good doctor will be willing to share this uncertainty with you. He can give you a list of his top three guesses, and then describe how he plans to eliminate them, one by one. Sometimes the doctor may not tell you what the name of the condition he suspects is, not because he wants to keep you in the dark, but perhaps because he doesn’t want to scare you with a serious sounding name. Other doctors feel that patients won’t understand the diagnosis anyway, while others assume that patients don’t want to know. ** Ask questions- It is hard to assess the accuracy of your diagnosis unless you understand what it is, and the basis on which it was made. Exactly what is the diagnosis? How sure is your doctor? What are the other possibilities? What other diagnoses has your doctor ruled out? What other related diseases are possible? Which ones have been tested for or ruled out? Dr Jerome Groopman, the author of How Doctors Think, suggests asking the following 3 questions: 1. What else could it be? 2. Is there anything that doesn’t fit? 3. Is it possible I have more than one problem? ** Get a second opinion - Getting the opinion of two or more doctors reduces the chances of a wrong diagnosis. If the two diagnoses match, then the chances of a wrong diagnosis are much lower. And if they don’t match, then this is a puzzle that needs to be solved in order to get to the correct diagnosis. Many online second opinion services allow you to consult with world-renowned specialists from the comfort of your home. Lots of health insurers also offer their customers a free second opinion service, to help them make sure that their diagnosis is correct. CrowdMed (www.crowdmed.com) uses the wisdom of the crowds to help solve diagnostic puzzles. It is an online medical crowdsourcing platform where you can submit information about your symptoms, medical history, tests, scan results and other pertinent data. This community of “medical detectives” then suggests diagnoses, and CrowdMed’s algorithms aggregate these medical differentials and distill them down to a probable list of diagnostic suggestions for you. This has an extremely high degree of accuracy, and is well worth exploring, especially when your doctor is stumped.

33. Patient Safety – Protect Yourself from Medical Errors 32 ** Step back and take a second look • Repeat the laboratory tests and scans- To reduce this risk, you can repeat the same test. This reduces the likelihood of a simple laboratory error or administrative mix-up, since this shouldn’t happen twice. • Run different tests- If there are multiple diagnostic tests for your disease, consider having another type of test done. • Use a different laboratory- If you don’t trust your test results, you might want to get them repeated at a different laboratory. • Keep the originals - To reduce the risk of becoming a victim of diagnostic errors, always make sure you have originals of your tests. Make extra copies, preferably in digital format. These can be very helpful if you need to get a second opinion. You should also make sure that your doctor examines your original scans and X-rays, and not just the reports, because his interpretation may be different from the radiologist’s. If you have undergone a series of scans, they should be arranged in chronological order, so that the doctor can compare them easily. • Research your disease- The best way to feel confident about your diagnosis is to be well- informed and understand how it was made, Knowledge is power! You can use an online symptom-checker to help you make sense of what the diagnostic possibilities are. The trouble with many of these is that they may needlessly scare you; so you have to resist jumping to the conclusion that you have an incurable medical disease when you go online. Patients are often the key to the right diagnosis Even though patients don’t have the medical tools and diagnostic skills that doctors do, they are the experts on their illness. An accurate medical history is the most valuable tool in helping the doctor to come to the right diagnosis, and often is far more valuable than expensive tests and esoteric scans. It was Sir William Osler who said–“Listen to your patient, he is telling you the diagnosis.” Sadly, doctors are often too busy to take a proper history, and patients are often too disorganized, as a result of which they may fail to provide the doctor with valuable medical clues. Make detailed notes about when your symptoms started; what makes them better or worse; what treatments you’ve tried so far; and how they are related to taking medications, eating a meal, exercising, or a certain time of day. By being clear, complete and accurate, and writing down your story in a structured format, it’s easier for the doctor to review your history, so he can make the right diagnosis!

34. 33 5 How overdiagnosis and overtreatment can lead to medical errors- and how to protect yourself The medical establishment has become a major threat to health. Ivan Illich. Medical Nemesis Laboratory tests and scan results form the scientific basis of present-day medical practice, because they provide a valuable window into what’s wrong with the patient. Modern medicine is therefore largely dependent on these tests as they help doctors to come to an accurate diagnosis. While it is true that lab tests can be very useful, they are often misused as well. With billions of medical tests being performed every year, modern physicians appear to be relying more on tests results rather than on their clinical skills to make a diagnosis. And testing often means big bucks for doctors because of the kickbacks diagnostic centers offer them to refer patients. The “defensive medicine” trend Many doctors have also started practicing “defensive medicine” in order to protect themselves in case they are sued by unhappy patients or their relatives for negligence. After all, few lawyers will find fault with a doctor who performed too many tests, but woe betide the doctor who fails to perform a test, if his patient falls victim to an unfavorable outcome!

35. Patient Safety – Protect Yourself from Medical Errors 34 However, testing can actually be harmful. Not only is it a financial drain, but it can also lead to a domino effect of spiraling testing, if the initial results are abnormal! And the more the medical interventions you are subjected to, the greater the risk for medical errors. Remember that if your doctor performs enough tests on you, the mathematical certainty is that he will find something wrong with you. And if he finds something wrong with you, he’ll usually end up treating you-whether you need treatment or not! However, such diagnostic labeling may be harmful to you, because the ‘diagnosis’ has now transformed you from a person into a ‘patient’, even though the abnormality may be a ‘red herring’ which has no significance to your medical problem! Many cynics call these abnormalities ‘incidentalomas’ (for example, a small fibroid in the uterus detected on an ultrasound scan), and these often result in unnecessary surgery as well, which exposes you to the risk of harm. Don’t forget that tests are not always benign. Invasive tests, that is, those that entail introducing instruments (such as endoscopes) or chemicals (such as radio-opaque dyes) into the body, generally, involve some risk of harm, which may include infection, allergic reaction, or injury to an internal organ. Sometimes, a test may lead to complications which are more dangerous than the benefit to be derived from the test results. While this is usually not the case, you need to consider the risk-benefit ratio of all tests, especially expensive and invasive ones! All tests have their limitations that patients need to understand. In other words, merely conducting more tests does not ensure better medical care; after all, the value of a test to the patient depends not only on the skill in interpreting its result, but also on the clinical judgment exercised in ordering the test in the first place. For example, when we carry out a semen analysis (sperm test) to check a man’s fertility, the question to which we seek an answer is: are these sperm capable of ‘working’ or not, i.e., can they fertilize an egg? Unfortunately, present-day tests simply cannot answer that question! A semen analysis simply provides an accurate count of the total number of sperm and their ability to swim, but because there is such a wide range of normality, the results cannot be used to predict a man’s fertility. Similarly, a positive skin test for TB (the Mantoux test) simply means that the patient has been exposed to the tubercle bacillus in the past (as most of us in India have been!) Such a result does not mean that the patient is suffering from an active TB infection, an erroneous conclusion many patients (and their doctors) still jump to. How can you protect yourself from over-testing? In the final analysis, remember that medical tests can be helpful in pinpointing your problem, but they need to be used wisely and well; after all, doctors do not treat abnormal test results, they treat patients. When a test is recommended, the single most important question you must ask is-How will the result of the test change the course of your treatment? And if the answer is that it really won’t, then maybe you don’t need the test at all!

36. How overdiagnosis and overtreatment can lead to medical errors 35 Here is a checklist of the important factors you need to consider before going in for a medical test. Medical Test checklist Test name _____________________________________________ Description ____________________________________________ Purpose ______________________________________________ To confirm diagnosis?___________ Diagnosis _______________ To exclude diagnosis? ___________ Diagnosis ______________ Where will the test be done? Clinic? _________ Independent lab?________ Hospital? _________ Cost of test in: Clinic _______ Independent lab ________ Hospital _______ Are there risks associated with the test (i.e., is the test invasive)? __________________________ If yes, what risks? _____________________________________ Are there less invasive tests that might give the same information? ___________________ ________________________ If the test result is abnormal what will be done next? __________ If the rest result is normal what will be done? _______________ COMMENTS ______________________________________ ________________________________________________ __________________________________________________ You should fill out this checklist for every medical test suggested. The more invasive or expensive a test is, the more important this checklist becomes. The hazards The hazards of over-testing often go hand in hand with the risks of its first cousin, overtreatment. The media regularly carry reports extolling the virtues of the newest technologic tools in medicine. How is a patient to make sense of which technology may be useful for his particular illness? New technology can be dazzling, and undoubtedly, when medical technology is used properly, it can save many lives. However, every rose has its thorns and technology can be a two-edged sword. For example, the introduction of antibiotics was very quickly followed by their misuse, leading to rampant antibiotic resistance amongst bacteria and an ever-increasing rate of hospital-acquired infections. We need to remember that new does not always mean better, and that time-tested medical procedures are often better than the latest gadget on the market!

37. Patient Safety – Protect Yourself from Medical Errors 36 Sadly, many new medical treatments gain popularity over older standards of care due to clever marketing, rather than any solid science. Most patients with complex chronic illnesses have a small army of very highly specialized doctors, each of whom treats the abnormal lab results in his own medical domain, while ignoring what the other specialists are doing, and not paying any attention to the patient at all! None of the doctors has a 360 degree overview of the treatment the patient is getting. The result can be dangerous medical chaos because modern medicine consistently violates the ancient advice of Hippocrates: “It is better to know the patient who has the disease than the disease the patient has.” Doctors love looking at medical images and doing procedures. They get paid a lot for doing these,whichiswhytheycontinuedoingmoreofthem!Inamorerationalworld,doctorswould care about risks and harms, and wouldn’t always be rushing to order pointless dangerous tests and treatments. Too many doctors, too many tests, and too many procedures, with no one keeping track is a recipe for disaster, and the disasters continue to happen. You can protect yourself by visiting the Choosing Wisely web site at http://www.choosingwisely.org. It provides information on a wide variety of harmful tests and treatments across many specialties. This website will teach you when to Just Say No to your doctor! Remember that the safest surgery is the one which is not done! Unnecessary screening tests To add insult to injury, doctors are no longer waiting for patients to fall ill. They are now converting well persons into patients, by “screening” them for illnesses. While this seems like a great idea in theory, because prevention is better than cure, this “testitis” means that even more unnecessary tests are being done on a much larger scale, and lots of blissfully unaware people are being sucked into getting medical care they do not really need. Unfortunately, due to the widespread fallacy that the human body is no better than a machine, we have been taught that the body needs ‘routine maintenance’ which should be performed by a doctor, much as your mechanic tunes up your car periodically. Many people effusively gush: ‘Doctor, give me the works, I want a full check-up!’ Many clinics now readily pander to this demand by providing a wide range of ‘executive health check-up schemes,’ but often these ‘schemes’ can be more harmful than beneficial ! In fact, routine tests, such as electrocardiograms, chest X-rays and full blood screening, have been found to provide little overall benefit for the healthy individual. The reason these health check-up schemes have become so popular is because they bring in the ‘moolah’! After all, much more money can be raked in by screening droves of healthy people, rather than by only taking care of sick patients. And then there is the additional lucrative bonus that the screening tests will ‘pick up’ abnormalities, thus converting a formerly healthy person into a patient who needs medical attention!

38. How overdiagnosis and overtreatment can lead to medical errors 37 In fact, the only routine tests that the US Preventive Services Task Force recommends are those for blood pressure, cholesterol, colorectal cancer, breast cancer and cervical cancer. This task force refused to recommend widespread screening for other diseases for two reasons: either the tests had been found to have no merit, or there wasn’t enough evidence to prove their benefit (i.e., they did not help to improve either life expectancy or the quality of life). In fact, screening tests could have a major negative impact on one’s health, which is why they should be undertaken with a great deal of discretion and caution! To see how much harm these apparently benign screening tests can do, let’s look at the highly publicized controversy over the need to screen men for prostate cancer, by ordering a blood test for determining the presence of PSA (prostate-specific antigen). The PSA test measures the level of a specific protein in the blood that can indicate cancer and other prostate abnormalities. The drawback with this test, as with most screening tests, is that an elevated level of PSA is not diagnostic of prostate cancer. In fact, a number of patients who are completely normal are found to have elevated PSA levels. Then, in order to prove that they are not suffering from prostate cancer, they will be subjected to a prostate biopsy, and sometimes even surgery to remove the prostate altogether. The adverse consequences of widespread screening include: ** A large number of false positive results, causing needless anxiety and concern ** Unnecessary biopsies ** Harmful effects of aggressive treatments for slow growing cancers that may never have caused symptoms in a patient’s lifetime and could have been left well alone. When less is more Modern medicine has finally realized that simple common sense measures to improve your lifestyle are much more effective than undergoing complex and exorbitant tests and scans for remaining healthy. The trouble is that these measures are greatly undervalued by patients due to their simplicity! It is futile to squander money on unnecessary tests during your check-ups. Remember that using your common sense is more important than getting a 20-page glossy computerized health checkup report. The reason for the current epidemic of avoidable care is that free-market medicine treats health care just like any other business commodity, and ends up putting profits before patients. For now, your only protection is being a well-informed consumer.

39. 38 6 Social media and the internet for reducing medical errors - how the wisdom of the crowds can improve patient safety Dinesh Chindarkar An old error is always more popular than a new truth. German Proverb A friend of mine suddenly collapsed at work. He found that he was unable to get up, because his legs were feeling like jelly. An ambulance had to be called for, to rush him to a hospital. The doctor on duty diagnosed him as having Guillain–Barré Syndrome, a name we couldn’t even pronounce! Had this scenario happened a few years ago, we would have worried enormously as to whether the doctor was on the right track. Suppose his diagnosis was wrong? We would have been forced to blindly depend on his competence. Technology to the rescue However, this being the 21st century, the patient’s daughter whipped out her smartphone and did a Google search on the disease. She was able to reassure her distraught mother that although Guillain–Barré Syndrome was a rare disease, most patients recover completely once it runs its course, and that the doctor was providing the right treatment. Instant relief- for both the patient and his family, and the doctor as well; because the patient’s trust in the doctor increased considerably after they had verified that his diagnosis made sense! There are many ways of accessing health-related information online. Many patients start by using search engines like Google and PubMed; others participate in online discussions started by patient health groups; while others post direct questions to doctors on their websites, blogs and social media accounts. Internationally, websites of well-known pharmaceutical brands such as Lipitor and Allegra offer accurate, scientific information in a consumer-friendly language. On Facebook, there are reams of pages dedicated to common diseases such as diabetes and arthritis, many of which are managed by non-profit organizations and healthcare companies. On Twitter, searching with a hashtag e.g. #diabetes, #cancer, #weightloss, #menopause can yield a wealth of information on various health aspects. On Pinterest one can follow the latest trends in healthcare through infographics and images. Websites such as Healthcaremagic. com, healthtap.com, and netdoctor.com offer an online consultation with a doctor for free, while others charge a nominal fee. However while discussing your symptoms and problems online through live chats, messages or emails with someone who is claiming to be a healthcare practitioner, please check the doctor’s credibility.

40. Social media and the internet for reducing medical errors 39 The queries on these forums are moderated by registered medical practitioners and their profile can easily be viewed on the website. Websites such as RateMD, MedeCure and DocSuggest provide a platform for patients to share their experiences with a doctor, and seek their opinion on other practitioners. From answering questions on portals to running their ownblogsforeducatingpatients,theinternetenablesdoctorstoimprovetheircommunication with patients. Many pharmaceutical companies have teamed up with mobile app developers for creating smartphone applications. This includes apps such as diet trackers, symptom checkers, and baby vaccination reminders. For instance, MuSugr is a diabetes management application that not only helps a patient track their blood sugar levels, but also features interactive games to improve patient engagement. Online support groups These are usually run by patients, and these virtual patient support groups can be very helpful. Reading other patient’s real life experiences helps you get a clearer understanding of what to expect during your journey, and expert patients will provide practical advice about treatment options, and how to guard against goof-ups. They can share some of the glitches and hurdles they have encountered, and learning how they overcame them can help you to protect yourself during your journey. You can choose to remain anonymous, so you feel secure. These forums also allow you to compare notes on resources, such as doctors and alternative options. Many patients find the advice here much more trustworthy than what they get from their doctors, because it is unbiased, and provided without a commercial agenda. However, not all support groups are above board, so you do need to be careful! Being able to talk openly and honestly about your emotions when you feel your doctor has made an error reduces distress and anxiety, because you now have a safe platform where you can vent, and you don’t need to bottle up your angst. You will be able to find online friends, who can counsel and support you, and will help you cope better.

41. 40 7 Health literacy is the safety shield against errors - How can you use it? Helen Osborne The greatest mistake is to imagine that we never err. Thomas Carlyle Many patients and their caregivers find medical care complex and confusing. This is where health literacy comes into the picture, and its goal is to ensure that patients know what to do, when, how and why. A common example Let’s say your doctor has prescribed some medication for you and has told you to take 1 pill, twice a day for 2 weeks. You nod in acquiescence and head back home. But you realize that there are a number of questions running through your head: ** What time should I take the first pill? ** How many hours later do I take the second pill? ** What if I forget to take a pill? Can I then take two pills at once? ** Should I take my pill before, during, or after meals? ** Can I take this pill with my other medicine?

42. Health literacy is the safety shield against errors - How can you use it? 41 ** My doctor said to call if I notice problems. What kinds of problems? ** How does this medicine help? Will it make me better? Or keep me from getting worse? This is not an uncommon situation, and health literacy can help make it safer for patients to take their medicines properly. What can you do? ** Prepare for your appointment- Make notes about your symptoms. For instance, you can note things like - “I get a dry mouth about an hour after taking this medicine. My mouth gets so dry that I cannot even eat bread.” By being clear and concise, it’s easier for your doctor to figure out what’s wrong and suggest what can be done to rectify it. ** Make notes during the consultation- You will be with your doctor for only a short period. It’s best to make a list of all the questions or concerns you have and take this list along. Don’t forget to carry a pen to jot down notes when the doctor is advising you about something. Once you’re back home, refer to these notes; you will find that you are much more confident about what you are supposed to do. You can also request your doctor’s permission to record the consultation. ** Let someone accompany you- Ask a family member or close friend to accompany you to the clinic. This is especially important if you think that the doctor will be talking about upsetting news or giving complicated instructions. The other person can be your auxiliary eyes and ears and he can talk with you later about what was discussed during the consultation. ** Ask the doctor questions- One of the best ways to avoid doubt is to have clarity about what you are supposed to do; and the best way to gain clarity is to ask the doctor questions. Though this seems like a logical solution, the fact is that your mind sort of clams up during appointments, and it becomes difficult to think of what to ask. Learn to ask your doctor these three standard questions: • What is my main problem? • What do I need to do? • Why do I need to do it? ** Test your understanding- The doctor may give you a large amount of information and a lot of it may be new, complicated, or confusing. Ensure that there is no fog in your mind before you leave the appointment. A good way to maintain clarity is to ask the doctor something like: “I want to make sure I understand these directions correctly. When you said, “Do _________, does this mean that I should __________?” How can doctors make medical care safer for patients? ** Educate patients- Patients need to understand their bodies and what happens when they are ill. This includes learning about basic biology and anatomy. You can help by keeping them informed about what takes place inside their body when they suffer from an acute illness like appendicitis or a chronic condition such as diabetes. Using illustrations, sketching a picture, or demonstrating on an anatomic model makes it easier for patients

43. Patient Safety – Protect Yourself from Medical Errors 42 to understand your explanations. Our book, Decoding Medical Gobbledygook – Health Literacy Puts Patients First at http://issuu.com/malpani/docs/healthliteracy, offer more suggestions as to what you can do to ensure that patients understand what you tell them. ** Check for understanding- Use the teach-back technique to confirm understanding. Start by saying something like, “I want to make sure I communicated clearly.” And then ask the patient to tell you in her own words what the key points of your instructions were. Ask simple things like - “When you go home, what will you tell (your brother, son, or someone else) about what we just discussed?” If you sense that the patient hasn’t correctly understood, then alter the manner in which you explained it the first time around. Once again, confirm understanding by using teach-back. This will help you to improve your patient’s safety quotient. ** Help your patients make sense of online information – Sometimes your patients may not follow your advice because of what they read on the internet. Sadly, a lot of websites are unreliable and outdated, and patients may get fooled and misled. To make sure your patients don’t get confused and befuddled when they go online, you can refer your patients to credible resources on the internet. Provide lists of websites and organizations that offer unbiased, evidence-based, patient-friendly health information. One excellent resource is Mumbai’s HELP (Health Education Library for People) which is online at http://www.healthlibrary.com.

44. 43 8 Patient advocates- Advocating for safety A patient advocate should have the negotiation skills of a diplomat, the curiosity of a child, the protectiveness of a mother and the courage of a freedom-fighter. Dr Aniruddha Malpani The poor patient’s plight Ekta is a 60-year old widow, who has diabetes, impaired kidney function and angina. Her family physician is under the impression that her cardiologist is tracking her health – after all, he has referred her to him because he is the specialist, and he is happy to defer to his expertise. Her cardiologist believes that Ekta’s care is being monitored by her family physician, as he feels that this is the responsibility of the primary care physician. And the nephrologist has no clue what the other two are doing! You can imagine how high the probability for medical errors is in this kind of situation, when the left hand does not know what the right hand is doing! She is a disaster waiting to happen. In a perfect world, doctors would talk to each other, and everyone would be on the same page. In real life, however, doctors are extremely busy. They have a tough time dealing with their ever-increasing workload and rarely have the time to communicate with their patients, or with the other treating physicians. This results in poor coordination, and the patient’s care often suffers due to the number of specialists she has to see. This means it’s become the patient’s responsibility to constantly be on their toes when it comes to taking care of their health. The patient advocate comes to the rescue Ekta finally found a patient advocate, who acts as her protective shield from medical errors. He is her knight in shining armor, because it’s his job to handle everything from accompanying her to the busy specialist’s clinic, to updating her medical records. Her patient advocate is her “go-to person”, who helps her navigate the complex healthcare maze. Patient advocates can be pillars of strength for patients during a very challenging phase of their lives. A patient advocate can be either a : ** Self advocate: If the patient has an adequate amount of medical knowledge and if her health permits, she can be her own advocate ** Informal advocate: A family member (spouse, sibling, parent or friend) assumes the role of a medical advisor ** Professional advocate: A social worker, nurse or any other health professional employed either by the hospital or the family, to act on behalf of the patient. Progressive health insurers now provide patients who have a complex chronic illness with a case manager, who acts as their patient advocate

45. Patient Safety – Protect Yourself from Medical Errors 44 A good advocate should have earned the patient’s trust; must understand her medical problems; and be assertive. He should be able to take a firm stand – after all, his job is to speak up for his patient! An advocate needs to be well-informed, and should be able to discuss treatment options with the doctor, on behalf of his patient. Patient advocates protect patients from medical errors by guarding the patient’s rights. They can: ** Provide insight into how the healthcare system works, and what to do when it doesn’t ** Facilitate access to leading doctors, if a second opinion in needed ** Help the patient to speak up when things aren’t going as expected ** Cut through the hospital red-tape ** Make sense of medical research ** Ensure that the medical team puts the patient’s interests first The patient advocate’s role during your hospitalization When you are hospitalized, you’re not on top of your game. A patient advocate becomes your friend, philosopher and guide, who watches over you while you are in the hospital. In the past, this role was performed by your family physician (who sadly seems to have become an endangered species today). Your patient advocate functions as your guardian angel, and his most important role is to ensure that there is no slip-up in the care that you receive. ** Your advocate needs to coordinate care with the various specialists in the hospital, each of whom seems to be in charge only of the organ system which belongs to his particular superspecialty! It’s important that he have the phone numbers of all the doctors who are caring for you, so he can get in touch with them directly, in case he has any questions. ** He should make friends with the nursing staff; they provide the actual hands-on care and are responsible for administering your needs. They have the answers to most of your questions, and are much more accessible than your doctors. ** He needs to be present at the change of shift duty, during the handoff or transition, when the nurses who are going off duty update those who are coming on duty. Passing the baton can be fraught with hazards, and he needs to make sure it is not dropped during the handover. ** Before you leave the hospital, your advocate should meet up with the hospital’s discharge planner – usually the nurse on duty. She can furnish important information about local resources and referrals to other medical professionals. If you require continued care at home or at a rehabilitation center, your advocate will assist with the transition. What makes doctors wary of patient advocates? The term advocate sounds adversarial, and doctors often get defensive when they have to deal with one. They can create hurdles in the patient advocate’s path and this negativity harms the patient’s care. This is why some advocates prefer calling themselves “patient champions”.

46. Patient advocates- Advocating for safety 45 His training and experience enables him to understand what the patient is going through, and he is in the right position to ensure that her unique medical needs are being properly met. The medical staff should understand that it’s the advocate’s job to monitor and oversee a patient’s care, so that the patient gets the care that the doctor has prescribed. They are both on the same side–the patient’s! It’s crucial for the advocate to remain polite, positive, encouraging, and appreciative; and to cooperate with every member of the medical team, so that he creates a win-win for everyone. At times, he may need to be firm, even demanding, but that cannot be an excuse to be impatient, short-tempered, rude or confrontational. If he wants his patient to get the best medical care, he should take care to be patient himself! A patient advocate is a very valuable resource that patients and their loved ones can turn to, so they can deal better with their medical challenges. Because a patient advocate can help improve the patient’s experience with the healthcare system, he should be recognized as an essential service provider in our healthcare system. You can learn more about what a patient advocate does in our book, Patient Advocacy-Giving Voice to the Patient at http://www.slideshare.net/malpani/dr-malpani-patient-advocacy

47. 46 9 How hospitals can be made safer- How to make sure “never “ events never occur ‘To err is human, to blame … even more so’ (unknown). It’s easy to feel powerless when you are hospitalized. Poorly designed hospital gowns which leave you half naked make it difficult for you to hold on to your dignity; and lying spread- eagled on the operation table can make even the strongest patient feel overwhelmed, scared and powerless. You are scared, and while the medical staff wants to help, they seem to be rushed and frazzled, and you are reluctant to intrude and upset their schedule. Unfamiliar territory Doctors have their hands full with patients and anxious relatives pestering them with questions. Nurses are multi-tasking and making copious notes on each patient. Residents are doing multi-shifts and probably haven’t had a good night’s sleep in several days (or is it weeks?). Hospitals are unfamiliar terrain, and can be a lot like a minefield. Hospital hazards for patients are hidden, but if you don’t know where the mines are, how will you be able to avoid them? Even though nurses and doctors will do their best to provide the best care for all patients, the bitter truth is that hospital care can harm – and this can be a steep price to pay, just because you are clueless about what you can do to protect yourself. Preventable hospital hazards can result in harm to patients, or even death. These are called “Never Events”, and include disasters such as:

48. How hospitals can be made safer- How to make sure “never “ events never occur 47 ** A retained instrument in the abdomen after an operation ** A mismatched blood transfusion because of the wrong blood bag being given to a patient ** Surgery performed on the wrong body part ** Surgery performed on the wrong patient In a perfect world, these kinds of disastrous slip-ups would never occur. While hospitals have their own safety training campaigns to improve their processes and protocols to stamp out Never Events, the fact remains that humans are fallible and that mistakes do occur. What can you do to ensure that these Never Events never happen to you or your loved one in the hospital? Partnering with the healthcare team is the best way patients can get the best care! However , some patients find that talking to their doctor can be challenging. Their fear is that it might upset the doctor, and damage their relationship. However, such worries are unfounded. Good clinicians routinely invite questions and help patients make intelligent decisions, based on their personal preferences. If you have any concerns, please ask your doctor or nurse. You have a right to ask questions and get answers about your own health. There’s no need to be confrontational, but you do need to be assertive. Sometimes it feels like your doctor is too busy to talk to you, or maybe you’re embarrassed to ask some questions. If you are scared, you can ask the junior doctor or the nurse your queries, but you need to remember that messages can get garbled during transmission. Remember that your nurses and doctors all want the same thing: for you to get better quickly. As the patient, you too are part of the health care team. It’s important that you prepare, listen carefully, and speak up when you need to. Because the time your doctor can spend with you is limited, you will feel less rushed if you prepare your questions in advance. Remember that Questions are the Answers, and the quality of the doctor’s answers will depend upon the quality of your questions! You can learn how to ask good questions at http://www.ahrq.gov/patients-consumers/patient-involvement/ask-your-doctor/index.html. Here are some useful suggestions. ** Speak up if you have any questions or concerns, and if you don’t understand the answers, ask again. It’s your body and you have a right to know. If you ask a question you may feel like a fool for a short time, but if you don’t ask, you will remain a fool for ever ** Don’t shy away from asking about safety. For example, if you’re having surgery, ask the doctor to mark the area that is to be operated upon, so that there’s no confusion in the operating room ** Notice whether your caregivers have washed their hands before touching you. Hand washing is the most important way of preventing hospital-borne infections. Don’t be afraid to gently remind a doctor or nurse to do this. This should be an “always event”- a positive behavior that improves patient safety. If truth be told, even big, established hospitals are often understaffed and their nurses over-worked. Studies show that only one-third of doctors and nurses comply with the hand-washing routine. However,

49. Patient Safety – Protect Yourself from Medical Errors 48 patients are hesitant to say anything because they don’t want to seem to be suggesting that hospital staff aren’t clean. Here’s a simple solution devised by Julia Hallisy, who is the founder of The Empowered Patient Coalition (http://empoweredpatientcoalition.org): “When our daughter was ill, we taped an eye-catching, easy-to-read sign to the door of her room. Using colored paper, we wrote ‘PLEASE WASH YOUR HANDS AND WEAR GLOVES AS APPROPRIATE’ in large, black letters. This simple reminder resulted in such an immediate and dramatic increase in compliance that the infection control specialist made her own signs and placed them on the doors to all of the rooms in the pediatric oncology unit.” ** Make a careful note of the time of the day when you receive your medication. If a nurse misses out the next dosage, remind her about it ** Educate yourself about your diagnosis, the medical tests you are undergoing and your treatment plan ** Ask health care workers to introduce themselves when they enter your room and look for their identification badges. If you are unsure about their identity or occupation, ask! ** Make sure your nurse or doctor confirms your identity from your wristband or asks your name, before he or she administers any medication or treatment. Don’t hesitate to tell the health care professional if you think he or she has confused you with another patient ** Verify that blood and other specimens taken from your body are labeled in front of you. ** Go to a hospital or clinic that is accredited and routinely undergoes rigorous on-site evaluation against established state-of-the-art quality and safety standards issued by the local medical authorities ** If you have any type of catheter or IV line, ask every day if that catheter and IV line can be removed. This can reduce the risk of hospital acquired infections ** Know your doctor and his team. Make friends with your nurses and the technicians – make sure they address you by name at least once every shift. ** While hospital management discourages tipping, a lot of family members find that giving gifts to the hospital staff helps to ensure that their patient gets VIP treatment. This isn’t something you should be doing as it encourages the hospital staff to discriminate between patients. ** Know whom to call for help in case of a medical emergency (how to activate a CODE Blue). ** Checklists can be your best defense against medical errors when you are hospitalized. They can serve as mine-detectors, and armed with the right checklists, you’ll know what to look out for. Equally importantly, these can teach you what to do, and what to say in order to get safe care. Even in the best hospitals, patient safety is a team effort. You can download comprehensive checklists free at http://patientsafetymovement.org/resources/#patient-checklists.

50. How hospitals can be made safer- How to make sure “never “ events never occur 49 In her book, Hospital Guide for Patients and Families, Julia Hallisy writes: “Don’t wait for staff members to breach protocol and then berate them. Avoid awkward situations by announcing your concerns to staff well in advance of the start of the procedure.” Your medical records Your medical records summarize your treatment course during your hospital stay, and are very valuable documents. While many hospitals treat these as their property, they are your records, and it’s a good idea to review them on a regular basis, to ensure that there are no errors in them. Some hospitals are reluctant to share the records with the patient, but this is an archaic attitude, and needs to be changed. You need to make sure that the notes are legible; complete and updated . All the lab results and scan reports should be filed in a timely fashion. If something is not clear or is missing , ask the nursing staff or the doctor. Patient complaints can improve patient safety You need to remember that as a patient, you are not just a passive recipient of medical care, but you can actively help to promote safety and reduce risk. One way is to complain if you have a bad experience, because these could be a result of unsafe systems and careless doctors. All of us have been in hospitals, either as patients or as visitors, and we know from personal experience that many hospital processes are broken. Since patients are at the receiving end of many near misses, patient feedback can help hospitals to promote positive changes. Patient complaints are also useful markers of dysfunctional doctors, and the systematic analysis of patient complaints can help the hospital management to identify high risk physicians. Typically, 80% of the complaints will involve 20% of physicians, and these are the ones who jeopardize patient safety, by being rude or cutting corners. The majority of these physicians are often not aware of their risky or unsafe technical and interpersonal behaviors. Patient complaints offer a powerful tool for identifying these error- prone, high-risk physicians and most physicians respond positively to feedback, because they know that this can help them to improve. Many will agree with the issues identified and will ask for help, while others may need to be fired, to stop them from harming other patients.

51. 50 10 Protecting yourself from medical billing errors- The need for vigilance A man who has committed a mistake and doesn’t correct it is committing another mistake. Confucius When you get admitted in a hospital, you are not just a patient, you are also a consumer. There could be times when the technical quality of your medical care may be great, but the administrative hassles you encounter may be a major pain point. A big issue is the complexity of the medical bills patients are presented with when they are discharged. These often run into pages and pages of fine print, full of undecipherable jargon, and sadly many hospitals slyly misuse the fact that patients cannot make sense of their bills as a ploy to pad the bills and overcharge them. You need to be vigilant to prevent becoming a victim of this scam, otherwise you can end up spending a pretty penny. Why errors occur The complex world of medical billing is ripe for errors. As many as 50 people- ranging from the nurse to the medical coder, could be involved in generating just one bill. With all of those hands touching your bill, it’s no wonder that as many as 80% of bills contain mistakes which will end-up wasting your hard earned money. It’s true that medical bills are difficult to decipher. They are loaded with numerical codes, confusing abbreviations, charges and payments. The primary step in identifying errors lies in understanding exactly what you’re looking at, and not being afraid to admit when something is confusing. The following three steps will help you make sure you pay the right amount, and are not fleeced. Step 1: Request itemized copies of all bills Every line item needs to be spelled out, so you know exactly what you are being charged for. Deciphering the bill can be a challenge, but it’s worth taking the effort to do so. As you go through your bills, mark everything you have a question about, so that you’re able to address these concerns later. For example, carefully check for duplicate charges to make sure you were not billed twice for a single service or procedure. With an itemized bill, it should be much easier to spot. Similarly, you may be charged for a test even though it was never performed, because the doctor cancelled it after ordering it. Going through your bill line by line will make sure you are not taken for a ride.

52. Protecting yourself from medical billing errors 51 Step 2: Verify dates of hospitalization and identifying information. Begin by checking the simple things. Ensure that all your personal information, contact details and insurance information are correct. Also double-check your dates of hospitalization. These seemingly small mistakes are quite common, but they can affect your insurance coverage or how much of the bill counts toward your deductible. Billing departments play games, and they can get creative with their billing. A common tactic is called “upcoding”, which involves billing someone for a more serious (and expensive) charge than warranted. If any charges are suspicious or simply seem far too high, mark them so you can ask about them later. Step 3. Ask for help, if needed Start by meeting the billing office staff. Take your time, and don’t be afraid to ask all of your questions. You are the customer here, and the medical providers are being paid for a service. You’ll get the best results if you are cordial even when frustrated, but don’t be afraid to ask the tough questions and get clarification when the answers aren’t clear. Reviewing your medical bills will take some time and effort, but if the tedious process saves you some money, it will be well worth it. Don’t allow financial errors to compound your medical problems!

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