Cameras 2

2014 Joint Commission goal for hospitals: Prevent mistakes in surgery.

2004 To prevent wrong-site and wrong-patient procedures, the Joint Commission mandated a three-step process known as the universal protocol. Yet a decade latter, that alone has not solved the problem. Mandating without a verifying mechanism like cameras is like doing nothing at all.


2008 The Joint Commission issues Sentinel event alert. Intimidating and disruptive behaviors in health care organizations are not rare. A survey on intimidation conducted by the Institute for Safe Medication Practices found that 40 percent of clinicians have kept quiet or remained passive during patient care events rather than question a known intimidator... Root causes and contributing factors
There is a history of tolerance and indifference to intimidating and disruptive behaviors in health care.

Study found that only half of all care follows evidence-based guidelines when applicable. 

Surgical Safety Checklists Reduce Post-Op Complications, so why do over 11% of patients die post-op due to treatable conditions?    Although checklists are considered a best practice in surgery, there is still variability in adoption and compliance rates in their use," 


Hospitals have hotly contested their post-op death rate scores saying "my patients are sicker, in worse condition".
Fact is the scores are weighted based on diagnosis billing codes at admittance, age,  sex, etc.  This provides the baseline at admittance to compared to post-op expected survival.

Understanding the numbers Medicare   Agency for Healthcare Research and Quality. 

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The survey for the “Disruptive Physician Behavior”  Over 50% responded failure to follow established protocols was common. Over 40% of root cause of disruptive behavior root cause was thought to be work load and learned behavior (e.g. med school)
  An estimated 550 to 650 surgical fires occur in the United States per year, some causing serious injury, disfigurement, and even death. Despite the cause being well known,  Are hospitals continuing to shortcut  prevention measures?

Joan Rivers case, Health and Human Services find, failure to follow established protocols.
QUOTESpecifically, it was determined that the facility 
FAILED to:
(1) Have a process in place to assure that only
authorized personnel are permitted in the 
procedure room.
(2) Have an effective process in place to assure
that only credentialed physicians can perform procedures.
(3) Ensure that informed consent is obtained for all procedures that will be performed and.
 (4) Ensure a "Time Out" (a pre-procedure protocol for verification of the correct person, 
procedure and site) was called to confirm each procedure to be performed.

As a result of the significant findings that were identified which compromised patient safety, an
Immediate Jeopardy.


Another survey of providers yielded the same startling results concerning disruptive providers. Over fifty percent of respondents saw failure to follow established safe protocols as a consistent problem with these disruptive providers.

Consider this: 1969 Apollo 13 controlled with less computer power than the cell phone in your pocket.  And we had real time video on TV! 
2014, hundreds of trillions of dollars in healthcare spending, medical errors number three cause of death, and still events inside operating rooms is kept a dark, well guarded deception.

Even though a surgery "Time out" is known to prevent errors:  Study of wrong-site and wrong-patient cases found 72% of the these errors, no time out was performed.

Many professionals think that wrong-site surgery is dramatically under-reported with only an estimated 10 percent of cases being reported to the Joint Commission. Knowledge of surgical mistake causes might help patients learn what to look and ask for when choosing a surgeon. Overbooking surgeries can lead to the one of the leading causes of surgical errors, referred to as "unusual time pressure." Poor cooperation and lack of respect between the surgeon and other team members could be hallmarks of a failure to communicate in the operating room.

Lack of physician compliance with evidence-based protocols may progress in efforts to improve outcomes and make hospitals safer, but a study of wider-scale standardization at the Mayo Clinic is showing promise as a means of getting doctors on board. Another resent report found use of one standardized protocol across 20 medical centers helped significantly reduce death rates among victims of stroke. “By treating every patient in the exact same way and preparing for each issue we may encounter, we were able to reduce patient mortality by about 50%,” said study author Dr. Douglas Chyatte of the Mayo Clinic Health System. 

Failure of bedside hospital clinical staff to follow established treatment protocols has been identified as a common factor in patients having an adverse event during their hospitalisation.  
You can probably guess some of the common causes of these cases: lack of policies or procedures to avoid retained surgical items, failure to adhere to policies/procedures already in place,

Only 10% of those who were responsible for a "never event" were disciplined at least once by their state licensing board. The authors found that physicians with clinical privilege or state licensure disciplinary action reports were more likely to be named in multiple "never event" reports than were those who had no reports of clinical privilege or disciplinary actions

Become empowered by signing this petition to have cameras put in operating rooms to ensure known safe protocols are followed.   NOT ignored.

2010 Conclusions  These data reveal a persisting high frequency of surgical “never events.” Strict adherence to the Universal Protocol must be expanded to nonsurgical specialties to promote a zero-tolerance philosophy for these preventable incidents.

Surgeon Relies on Memory, Removes Wrong Kidney "... failure to follow protocol 

Cameras As a result, compliance increased from 6.5% to 81.6%.  Some hospitals and doctors have expressed concerns that these recordings would encourage more malpractice suits. Makary said there were similar fears when patients began getting access to their CT and MRI scans, and he said this development didn't drive up litigation.

Cameras in rooms improves patient safety by reduced patient falls by 20%!

Some researchers say doctors have much to gain from these videos, similar to how professional athletes watch game tape to detect flaws and hone their technique.

A few hospitals are leading the way, while the majority will likely never change without legislation that mandates Known Safe Surgery Practices.

A “black box” installed in a Toronto operating room earlier this year has found that surgical teams are making the vast majority of their errors during the same two steps surgery after surgery.
Now researchers are looking at how to reduce those mistakes and prevent similar slips in the future.
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Marty Makary, a surgeon at Johns Hopkins School of Medicine and author of a bestselling book on patient safety, said two examples of video recording show the potential benefits for both patients and doctors.
After telling them they were being filmed, the mean inspection time increased 49% and the quality of inspection improved 31%.


Marty MaKary MD is pushing for the use of video cameras in operating rooms to better monitor quality and technique, and for standardized national requirements for hospitals to report adverse events resulting from surgery. This way hospitals can learn from their mistakes using peer review and video-based coaching for quality improvement.

Hospitals should also be required to make available the data on their adoption of best practices, such as procedures done with minimally invasive laparoscopic methods that are associated with lower infection rates, reduced pain, and better outcomes, versus open surgery.
"There is tremendous potential if we want to take quality to the next level and get serious about waste in healthcare," Makary said. "We should utilize the record button that is already there on these devices."
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Going to every effort to keep the truth from the public has only made medical culture worse, and more to hide, and cover-up.  Eventually, the one thing that moves hospitals the fastest is patient deaths and botched surgeries that have been made publicAfter public relations disasters happen, you're much more likely to see cameras in operating rooms," along with other accountability measures.

Decades of hospital's continuing buying media silence have now set the fuse on the powder keg of corruption even the best providers feel trapped on top of.
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