Posted by Sten Westgard, MS
Earlier this month (July) I came across a series of revealing posts on a listserv about the quality of glucose meters. For me, it raised the question, just what defect rate is acceptable at the point of care?
- 0.00034%
- 1%
- 5%
- 10%
- 40%
- 75%
- 100%
What level of defect rate do you believe is being seen at the point of care? the answer (after the jump) might astonish you...
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Posted by Sten Westgard, MS
Posted by Sten Westgard, MS
Posted by Sten Westgard, MS
While we recently got a study that estimated the (frightenly high) number of Adverse Events caused by US hospitals, it looks like other countries are not content to let us stand alone. Now Sweden is doing us one better. Guess what the Adverse Event rate is in one hospital in Sweden?
- 28.2%
- 20.5%
- 6.3%
- 3.32%
Which number would you choose?
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Posted by Sten Westgard, MS
Posted by Sten Westgard, MS
Posted by Sten Westgard, MS
Posted by Sten Westgard, MS
We've all heard the infamous quote now over a decade and a half old: that US hospitals kill between roughly 40,000 and 90,000 patients each year. This was an estimate courtesy of the Institute of Medicine report "To Err Is Human" which made the dire performance of hospitals knowledge that even the general public could understand.
But more recently, studies have been tracking the adverse event rates much more closely. A recent NEJM paper followed four conditions from 2005 to 2011.
Of these four conditions, which do you think has the best Sigma performance when it comes to the occurrence of adverse events?
A. Acute Myocardial Infarction (AMI)
B. Congestive Heart Failure
C. Pneumonia
D. (other) Conditions Requiring Surgery
The answer, after the jump...
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Posted by Sten Westgard, MS
In a recent issue of CCLM, an interesting opinion paper reported on a pilot study of the quality of UK laboratories.
Given 5,812 QC data points on 5 different platforms in 9 different laboratories measured over 6 months, and a quality goal of 7.0% how many of those laboratories do you think achieved 5-Sigma quality?
- 100%
- 75%
- 50%
- 25%
- less than 25%
The answer, after the jump...
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Posted by Sten Westgard, MS
Posted by Sten Westgard, MS
It's almost mandatory that any presentation or report discussing patient safety references the landmark IOM report of 2000: To Err is Human - Building a Safer Health System. The takeaway quote from this report is that US hospitals were causing 44,000 to 98,000 deaths that were otherwise preventable. That is, hospitals were causing tens of thousands of avoidable deaths.
A recent paper has attempted to revise that estimate, focusing on Preventable Adverse Events (PAEs) that contributed to the death of patients. Can you guess how lethal US hospitals are now?
- 4,000 to 10,000 PAEs per year
- 44,000 to 98,0000 PAEs per year
- 100,000 to 200,000 PAEs per year
- 210,000 to 440,000 PAEs per year
The answer, after the jump...
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Posted by Sten Westgard, MS
Posted by Sten Westgard, MS
Anyone heading off to Milan this May?
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Posted by Sten Westgard, MS
More evidence of pre-analytical error rates, this time for the Journal of Clinical Pathology. This is from a study back in 2010, my apologies for only finding it this year:
A Six Sigma approach to the rate and clinical effect of registration error in a laboratory, Naadira Vanker, Johan van Wyk, Annalise E. Zemlin, Rajiv T Erasmus, J Clin Pathol 2010:63:434-437.
In this study, they reviewed 47,543 test request forms from a 3 month period of November 2008 to February 2009. The study was conducted at the "chemical pathology laboratory at Tygerberg Hospital - an academic tertiary hospital in the Western Cape Province of South Africa. The laboratory is a division of the National Health Laboratory Services, which is a network of 265 pathology laboratories in South Africa."
Can you guess how many errors they found? And what was the impact of those errors?
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Posted by Sten Westgard, MS
I recently got a smart question from a concerned laboratory scientist. After reviewing one of the Sigma-metric studies on the website, he noted that while a particular method had a bad Sigma-metric, the main reason was due to the bias. His question was essentially (and I am paraphrasing here), "If the bias component comes from a particular difference between the instrument or kit and a reference system, shouldn't it be excluded from the Sigma-metric calculation?"
The reasoning is that the bias problem could be (1) eliminated through recalibration, (2) it may be a bias against a method that is not a reference method, so the difference might not be "real", or (3) if the reference range is adjusted and the method is used in exclusion, bias doesn't matter anyway.
We've had a lot of discussion about bias in our statistics lately. Is this a case where the Sigma-metric is "skewed"? What's your verdict? A discussion after the jump.
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Posted by Sten Westgard, MS