Failing to check all the boxes ...

Michael Grossman Michael.Grossman at MIHS.ORG
Thu May 2 16:36:00 UTC 2013


Utilizing well designed check lists are an important discipline in decision making allowing documentation of appropriate function (of an instrument , the light on the endoscope works, or the patient identification is correct, correct site of surgery, etc.) These measurable issues are under the domain of CERTAINTY.
Clinical problems may be fraught with much UNCERTAINTY, in the absence of complete knowledge or known data etc.  Clinical presentations have innate complexity and certain disagreement adding to the difficulty of diagnostic accuracy.
Our clinical reasoning skills are enhanced by information technology assistance , but still requires analytic review by the seasoned clinician. Type 1 thinking seems to increase with the age and seasoning of most clinicians further adding perturbation to  the complex adaptation systems in play
Superimposed on that the recognition that mechanical instruments do fail even after exhibiting function on testing ( as aircraft do have occasional significant accidents on or shortly after take off)
We strive to prevent error and to better define our decisions. One of the more important points we need to add is that after a clinical decision is made ( with the concurrence of the well informed patient) close follow up is required to assure that the clinical course is as predicted. If not, intervention and reevaluation is mandatory as quickly as possible. This latter avenue is essential to allow possible correction.

From: Robert Bell [mailto:rmsbell at ESEDONA.NET]
Sent: Thursday, May 02, 2013 9:24 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: Failing to check all the boxes ...

Medicine is too complicated and the mind too immature and small to effectively make sound diagnoses in all cases. When we get to that magical black hole point where computers are more intelligent than us, perhaps we can then use say three computers all programmed differently to crunch all the data in different ways to help reduce error rates, but presumably never perfect. The computers a bit like three or more high powered specialists taking a look at the case.

And by then we may have better tests to help us make quicker and and better diagnostic decisions. But then we will have to deal with the value of any treatment given. Onward and onward into the middle of that mysterious black hole. Bring on Singularity!

But right now it is a disaster for far too many.

Meanwhile a list is likely to to be helpful.

Rob Bell

Sent from my iPad

On May 1, 2013, at 8:16 PM, Michael.H.Kanter at KP.ORG<mailto:Michael.H.Kanter at KP.ORG> wrote:
i agree with you on the flying being prefered over going to an ED,but not for the reason you state.   I would take a well trained pilot without a checklist over a doctor who has a checklist but no concept of teamwork, collaboration, safety culture, and human factors knowledge but is using the checklist in a mechanical non thinking fashion.  Yes, we see the pilots using the checklist but that is simply what we see.  What we dont see is their attitudes about the checklist.  As an example, for years blood transfusion required two RNs using a checklist and reading off identifying information and blood types and unit numbers yet the wrong blood was still hung not infrequently.  The checklist may be necessary but it is far from sufficient.

Michael Kanter, M.D.
Regional Medical Director of Quality & Clinical Analysis
(626) 405-5722 (tie line 8+335)
THRIVE By Getting Regular Exercise

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From:        Lorri Zipperer <Lorri at ZPM1.COM<mailto:Lorri at ZPM1.COM>>
To:        IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Date:        05/01/2013 04:43 PM
Subject:        Failing to check all the boxes ...
________________________________



From: Nonie Leonidas [mailto:nonieleonidas68 at gmail.com]
Sent: Wednesday, May 01, 2013 5:36 PM
To: Society to Improve Diagnosis in Medicine; Michael.H.Kanter at kp.org<mailto:Michael.H.Kanter at kp.org>
Subject: Re: Lack of time, knowledge or just sloppy thinking? ... Failing to check all the boxes ...

Hi Micheal,

The next time you fly please take the first row, in smaller plane, and watch what the captain and co-pilots are doing.

They are minding their checklist, checking them off, and the co-pilot checking it again.

When both of them are sure that all of the boxes had been checked-off, that is the only time they will lift-off.

And that is the reason why I would fly any day rather than visit a doctor or an ER.

Nonie Leonidas
Philippines

On Thursday, May 2, 2013, wrote:

In my view it is not the checklists per se but also the culture that accompanies the checklist that creates safety and reliability.  Checklists alone do not add all that much value



Sent with Good (www.good.com<http://www.good.com/>)



-------- Original Message --------

From :      Alan Morris <Alan.Morris at IMAIL.ORG<javascript:_e(%7b%7d,%20'cvml',%20'Alan.Morris at IMAIL.ORG');>>
To : IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<javascript:_e(%7b%7d,%20'cvml',%20'IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG');>
Cc :
Sent on : 05/01 07:07:38 AM PDT
Subject : Re: Lack of time, knowledge or just sloppy thinking?

If we did this to pilots, no one would fly.
Paradoxically, we have tools to address this – but virtually no support of interest from funding agencies to pursue development.
Have  a nice day.

Alan H. Morris, M.D.


From:  "Dr.Will" <dr.will at fuse.net<javascript:_e(%7b%7d,%20'cvml',%20'dr.will at fuse.net');>>
Date:  Wednesday, May 1, 2013 7:54 AM
To:  'Society to Improve Diagnosis in Medicine' <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<javascript:_e(%7b%7d,%20'cvml',%20'IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG');>>, "Alan H. Morris, MD" <alan.morris at imail.org<javascript:_e(%7b%7d,%20'cvml',%20'alan.morris at imail.org');>>
Subject:  RE: Lack of time, knowledge or just sloppy thinking?

Yes and EMR data entry requirements have exceeded human capability to provide good clinical care (and both eyes and physical contact on patient) in the compressed time allotment by insurance payment and hospital owned productivity requirements. No wonder there are errors in DX and Outcomes.

If we did this to pilots, there would be more errors, as well. My brother is a retired pilot.

Will Sawyer, MD






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