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Things That Make Me Worry About My Colonoscopy: Patient Safety

officer at periscope in control room of submarine 150x150 Things That Make Me Worry About My Colonoscopy: Patient Safety leanSorry to get all Katie Couric on you, but I’m going to have a colonoscopy on Friday. I turned 40 last October and I have some family history that leads my doctor to get one done now rather than at 50.

Unlike Katie, I won’t be broadcasting mine live, but I’ll share some articles and reflections on the process and, being process focused, what could go wrong. It’s a very necessary procedure, but there are, sadly, some very unnecessary and preventable risks.

According to  Dr. Wikipedia (backed by journals):

This procedure has a low (0.35%) risk of serious complications

That’s about 1 in 300 patients, put another way.

For those of you who speak Six Sigma, that’s a 99.65% first time yield and a 4.2 sigma level.

That’s not going to scare me away.

Maybe I should have asked what my physician’s complication rates are. What are the complication rates at the surgical center where this will be done? Is this safer than being at a full-blown hospital or doesn’t it matter? Should I be more of an “engaged patient?”

Should I have asked more questions of my primary care provider? Why did she refer me to this GI specialist? Is he a “Best” doctor? Does that matter?

If I treat them as a supplier (respectfully), should I be able to walk the process and see what they do to prevent, say, instrument or scope disinfection errors?

Should I have asked:

  • Show me how you disinfect the equipment
  • Show me your training records for the people doing this work
  • Show me your equipment maintenance records
  • How do you verify that the work is being done properly?
  • Have you had any complaints or incidents in the past?

I had my pre-procedure phone call on Monday. Maybe I should follow up and ask a few of these questions, even if I can’t go “walk the gemba” to check things out myself. What would you do?

Of course, I didn’t have data or information available to me to know:

  • Which specialist is best at this?
  • Who has the highest or lowest complication rates?
  • What are the prices for different doctors or locations?

I don’t know how a busy person makes an informed decision.

These problems seem to happen way too often:

Dirty Instruments Lead to Investigation of Seattle Hospital

A Seattle hospital is under investigation after hospital officials revealed that more than 100 patients were put at risk of infection because medical instruments were cleaned improperly.

A breakdown in training resulted in instruments used during colonoscopies being improperly cleaned, hospital officials said.

Scopes used during colonoscopies were found to have been cleaned improperly last November, according to a hospital statement.

Technicians used improper cleaning techniques on the scopes between July 2011 and November 2013, hospital officials said. As a result the hospital has started notifying 106 patients who were at risk of infection as a result of undergoing a colonoscopy during that time.

We’re going to look for what went wrong and what can be done and what has been done to stop it from happening again,” agency spokesperson Donn Moyer told ABCNews.com.

Why was there a breakdown in training? What are other hospitals doing to prevent this same problem? It’s good to react using good problem solving and improvement mindsets (looking at the process, figuring out how to prevent reoccurrence), but you can prevent these incidents to begin with?

Dirty Endoscopes Raising Alarms for Colonoscopies

A new study disturbingly discovered that an average of 15 percent of flexible endoscopes used to examine GI tracts and colons at five hospitals were harboring “bio-dirt”–cells and other material from previously examined patients. This was even after the instruments had been cleaned.

And that yucky finding is likely to be matched at other hospitals across the country, according to study author Marco Bommarito, Ph.d, lead research specialist at 3M’s infection prevention division.

“During a day [a single] scope may be used on half a dozen to a dozen patients–maybe even more.”

The article also says:

A guideline issued by the American Society of Gastroenterology said documented cases of infectious complications from endoscopic procedures were as rare as 1 in 1.8 million procedures.

But Bommarito thinks the actual number might be higher. He noted that it will not necessarily be obvious that a person’s disease came from an unclean endoscope used on them.

So you have detection problems and self-reporting problems. Will some healthcare organizations cover up problems and not inform patients?

Atlanta surgery center admits error in cleaning colonoscopy equipment

“One of our physicians asked the staff, ‘how do you clean these instruments?’ It was through that process, they identified that we weren’t using the high-level disinfectant,” Hamby said.

I realize “bad process” and “bad process management” runs rampant in healthcare. Poor training. Poor supervision.

These are not worker problems — they are management problems.

Lawmakers Blast VA Over Bad Colonoscopies

“What stops contaminated fluids from backing up into this tube is this crucial green valve,” he said, illustrating with a colonoscopy tube. “Investigators found not only was this valve missing, but this tubing wasn’t being cleaned in between patients.”

In surprise inspections at 42 VA medical centers on May 13 and 14, investigators found that only 43 percent had standard operating procedures in place and could show they properly trained their staffs for using their equipment.

Unclean Colonoscopy Equipment Affects 64 Colorado Patients

According to Denver’s 9News , patients who had colonoscopies between July 17 and Aug. 13 were being contacted via telephone and mail and told to be tested for HIV and hepatitis after it was discovered that the hospital’s disinfecting machine was not working properly.

St. Charles: Colonoscope Not Fully Sanitized

According to the suit, filed last week by attorney Jennifer Coughlin, the hospital failed to fully disinfect a scope that had been used on four previous patients last September.

A letter to the woman from St. Charles CEO Jay Henry acknowledged a programming error led to the final disinfecting steps to be skipped.

Hospital removes chief exec after dirty tools risked 2,500 veterans

The Miami Veterans Administration (VA) hospital is holding its chief accountable for improperly washed colonoscopy equipment that may have exposed 2,500 veterans to diseases, reports the Miami Herald.

After the colonoscopy scandal, the VA’s Administrative Investigation Board began inspecting the Miami VA facility and found it to have “poor quality control, lax supervision and sloppy procedures,” notes the Miami Herald.

Tainted Colonoscopy Equipment a Wide Spread Concern

Secretary Shinseki confirmed this was not a one-time or limited place occurrence. Shinseki went on to say this concern is shared system wide across VA hospitals, clinics, and medical facilities. 

Shinseki’s analysis concluded this problem was not the fault of a person not doing their job. Instead, this situation presented itself because of lack of proper standards being in place in all VA medical facilities. Following the investigation into the problem, more proactive procedures were put into place to make sure this practice does not continue.

Endoscopy doc ran dirty, dangerous clinic: Report 

A cluttered procedure room with five combustible oxygen tanks, “questionable” air quality, possible patient exposure to toxic fumes, contaminated garbage under the procedure table and a lack of monitoring of patients’ vital signs during procedures.

However, the most troubling of the observations are related to the possibility of dirty devices used during the scope procedures.

Some, like biopsy forceps, weren’t being sterilized using the right equipment, the report says.

During one procedure, inspectors watched the doctor dip forceps in a formaldehyde solution to get rid of a specimen and reinserted the forceps into the patient’s esophagus.

Healthcare is in no position to get on a high horse and lecture Toyota or GM about quality, eh?


mark graban lean blog Things That Make Me Worry About My Colonoscopy: Patient Safety leanAbout LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as the new Executive Guide to Healthcare Kaizen. Mark is also the VP of Customer Success for the technology company KaiNexus.

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21 Comments on "Things That Make Me Worry About My Colonoscopy: Patient Safety"

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  1. Chad Walters
    Twitter:
    says:

    Welp, that’s scary enough stuff to make me wait on mine. And the picture you used is laugh-snort-worthy. :)

    But seriously, the inability to properly screen and evaluate multiple medical service providers for quality, price, and customer satisfaction with so much money and health riding on the line is somewhat mind-boggling.

    And I would also think that there should be set medical standards and perhaps mandated cleanliness processes for such invasive procedures that can very easily be checked and confirmed by both the medical staff AND the patients doing research. (Maybe there are. I’m no medical researcher or code reader.)

    What you have shared is enough to make me ask a whole lot of questions of anyone doing a procedure on me. I’ll try not to dwell on it for a while, though. Best of luck to you.
    Chad Walters recently posted..MLB Instant Replay Still Absorbing A Lot Of TimeMy Profile

  2. Joel Gross
    Twitter:
    says:

    Mark – here’s a tip for improving your experience. Ask them to take their time and make the end of the procedure last longer. Don’t believe me?

    Reference: https://www.amherst.edu/media/view/231465/original/colonoscopy%2B2.pdf
    In all seriousness, best of luck!
    Joel Gross recently posted..Why You Should Jump to SolutionsMy Profile

  3. BS says:

    It is remarkable that a restaurant can be shut down because a server doesn’t have a food handler’s permit or they stored raw chicken next to the salad greens when cleaning techs aren’t certified and there isn’t even a standard process for cleaning in the GI Lab and the GI Lab gets a pass.

    I was in a Waffle House (unique experience for me out west) a few years ago (walnut carmel waffles anyone?) and they actually had a small dish washing machine front and center behind the counter.
    Maybe GI Labs should have their cleaning room and scope washers visible to those in the waiting room (glass partition).

    I knew my own GI Lab had scope cleaning issues and everything was rush rush to stay on budget so I went to a system hospital 40 miles down the road for my scope. Wasn’t bad at all although when you get your bowell prep, ask for the optional toilet seat belt. It might come in handy.

    • Mark Graban
      Twitter:
      says:

      I know there are “kitchen nightmares” (if you have seen that show) where you have restaurants with poorly trained people and a lack of adherence to standards. I wonder if the average restaurant gets inspected more than the average endoscopy center. Knowing how bad hospital processes can be (poor training, poor supervision, focus on speed and cost), I think I am not being alarmist about the risks I face on Friday.

      I will not be live blogging or tweeting from the toilet on Thursday night, trust me.

  4. Jose perez says:

    Why the instruments for this type of procedures are not disposable?

  5. Jose perez says:

    Mark, thanks for replying to my question; however, if the cost is really the answer, it rises more questions. For example, as a patient, I’d be willing to pay the extra cost instead of facing the risk of using used equipment.

  6. Valerie says:

    Mark,
    Add to this scary information the need for correct labeling of specimens. Nothing worse than going through a colonoscopy only to find out later that your specimens were mislabeled with another patient’s identification and that each container’s contents didn’t match up with what was identified on the label. This is a huge issue that isn’t being addressed enough as patients are wheeled in and out too quickly to label specimens correctly during the procedure.

  7. Paul Everett says:

    Mark,

    I am 76, 77 in May, and I’ve never had a colonoscopy. (and this site doesn’t know the word either, it’s showing it as misspelled.) My doc wanted me to have one when I was 75 so I did a bunch of on-line reading and found out that the risk of perforation was 4% and more. To me, that’s serious. I also found out that a large study said that doing a colonoscopy on someone my age did not extend life expectancy. Not sure why, but that was the study outcome.

    I’ve had several sigmoidoscopies when I was having stress-related symptoms in my 30′s and 40′s and they found precusors to ulcerative colitis in the colon. Undertook meditation regimen and it all went away.

    If you have a family history of colon cancer, that’s a different proposition. So, I wish you the best possible outcome—nothing is found and nothing else happens.

  8. Mark Graban
    Twitter:
    says:

    Interesting discussion about this also on LinkedIn:

    LINK

  9. Mark Graban
    Twitter:
    says:

    Interesting from NPR:

    Two Questions For Your Doctor Before A Colonoscopy

    Unfortunately, unless the test is performed by a skilled physician with a good record of detecting polyps, all that effort may be wasted. “The biggest problem with colonoscopy is that it’s operator dependent,” says Dr, Douglas Rex, director of endoscopy at Indiana University Hospital.

    A skilled physician should have a polyp detection rate of about 25 percent for men and 20 percent for women, says Dr. Durado Brooks, director of prostate and colorectal cancers for the American Cancer Society. Those figures correspond to the percentages of men and women over 50 who have polyps.

    Another key indicator is the “colonoscopy withdrawal time,” which measures how long a physician takes to remove the scope after reaching the beginning of the colon. Longer is better, within reason. A withdrawal time of at least six minutes is associated with higher detection rates. Ten minutes is optimal, according to an analysis published last year.

    “The colon is a very twisted organ, and you may see things on the way out that were missed on the way in,” says Brooks.

    I”m going to ask those questions… Friday morning??
    Mark Graban recently posted..#Lean *IS* about Doing More with Less, But Be Careful Saying ThatMy Profile

  10. Mark Graban
    Twitter:
    says:

    I forgot to include this story…

    On Monday, I was on the phone answering questions for them about my medical history, etc. They then talked me through the “Moviprep” process, not eating on Thursday, etc.

    I said, OK so I can have clear broth and some plain yogurt an hour before taking the Moviprep.

    The guy says, “No, why do you think that? No yogurt.”

    I said, “Um, I’m looking right at the Moviprep instructions from the pharmaceutical company and the drugstore instructions say the same thing.”

    He says, “No,you have to follow OUR instructions. Do you still have them? Ours are different. We’re a little more careful.”

    At least we discovered that on Monday.
    Mark Graban recently posted..Kaizen Tip: Just Do Its and Root CausesMy Profile

  11. Randy Cole says:

    Mark, great article and great subject matter. My contribution to the discussion is still on-topic, however, using a different example…

    My wife is a 3-time cancer survivor. The reason she is still around is because she WAS (and is) an informed patient who actually DID do the research on the doctor(s), facility, reputation, success and survival rates and much more (personal interviews, with doctor and staff, etc.).

    In looking back, we both feel these efforts and the resulting tidbits of information (or… dare we say gathering ammunition for a battle well fought) led to wise and careful decisions that at least stacked the deck in her favor and influenced a strongly positive outcome.

    The last treatments are now many months behind us (good partners carry the burden together) however circumspect awareness and living habits that help keep a recurrence at bay are still called for. In essence, learning to live as (cancer) lean as possible and doing YOUR homework (no one can do it for you) did pay off.

    Sorry if that strayed a bit too far from your original intent.

  12. Mark Graban
    Twitter:
    says:

    I’m supposed to be “not working” but I am home and in bed.
    Everything went well.

    I decided to, basically, put it in God’s hands, or however you’d want to put it.

    I talked with a good friend who is an airline pilot and patient safety / TeamSTEPPS expert. We decided that me asking questions wouldn’t provide any meaningful answers. He said that “the next generation will benefit from the work we’re doing now to improve the culture for patients.”

    There’s nothing unique about risks with colonoscopies. There are risks all around healthcare. See here.

    The prep wasn’t that awful actually. It wasn’t fun last night and 2:30 am and 4:00 am, but the MoviPrep solution wasn’t that bad to drink.
    I was treated promptly today, with caring and friendly nurse, MD, nurse anesthetist, etc.

    I was given propofol, which I am assuming (bad to assume) that my insurance covers. Some insurance companies don’t consider that “medically necessary.” I had a $500 out of pocket payment for the center and MD. I might get billed for anesthesia, but not sure.

    With the propofol, it stung my vein a bit as they warned me, but it wasn’t that bad and I fell asleep. I woke up in a recovery room with my wife there and it was like waking up from a nap.

    If the experience is that pain-free for everybody, there would be NO concerns about getting this valuable test.

    They found no polyps or any concerns. No, it’s not a HIPAA violation to talk about my own care :-)

    Now, I will just hope I don’t get a letter in the mail someday about them discovering a problem with disinfecting equipment…
    Mark Graban recently posted..Video: Formula 1 Pit Stops 1950 & Today… a Huge DifferenceMy Profile

    • BS says:

      Good news about no findings. I hope you’re cleared for at least another 5 years. My own experience was similar. No need to worry about personal modesty. I was told by a staff member that when you have seen one, you’ve seen them all.

  13. Christian Echegoyen says:

    Mark,

    Glad to hear everything went well with the procedure.

  14. Mark Graban
    Twitter:
    says:

    My post was also cross-posted on The Healthcare Blog and there’s good discussion there, from a slightly different audience.
    Mark Graban recently posted..Video: Formula 1 Pit Stops 1950 & Today… a Huge DifferenceMy Profile

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