checklist vs. checklist

Peggy Zuckerman peggyzuckerman at GMAIL.COM
Fri May 3 16:12:43 UTC 2013


Re Mark's study showing "* value in being alerted to patients at highest
risk for dx error (patients arriving
with a diagnosis; patients seen in the ER a few days ago, etc)".  *This is
a critical point, as it underscores the common theme of an earlier
diagnosis confounding or blinding the next and the next provider to accept
without question that the first "read" or interpretation is correct.  This
is no doubt tied to the issue of seeking efficiency, and that of not
wanting to be the nay sayer or oddball in the group think that can
accompany this.

In my kidney cancer world, there are countless stories of patients being
treated for a diagnosis offered by the initial doctor, used as the basis
for a varying treatment by a second, all without benefit until someone
takes a fresh look.  Relying on an older mistake must be very frequent and
hard to discard!

Peggy Z


On Fri, May 3, 2013 at 8:02 AM, <Bettygene.Egan at kp.org> wrote:

>
> I have been reading the numerous emails on this subject and find the
> dialog robust.  It is also clear that this is a very challenging area with
> many opinions.  Ross and Harold's comments relate to a project that I have
> been working on and some of you may recall seeing at last year's DEM
> Conference in Baltimore.  Dr. William Strull and I briefly talked about a
> tool for patients named SMART Partners.  S=symptoms, M=medication/medical
> history, A= assessment, R= review, T= to do.  The concept of the SMART
> Partners is to provide patients with a tool to help prepare them for their
> appointment and to be engaged in their care, a checklist of sorts for the
> patient.
>
> I ran a very small pilot in one of our medicine clinics and the results
> show that the patients like the guide, 86% (n=590) said they will use it at
> a future visit.  A post-survey for the physicians shows an increase in
> obtaining information from the patient in the first couple of minutes than
> before using the guide.
>
> My point is ... I don't believe that we will ever be able to stop errors
> from occurring, similar to we will never stop car accidents from happening,
> however, as we remain open to opportunities for small changes, like seat
> belts, we can continue to minimize the risks. Small changes can have big
> impacts.
>
>
>
>
>
> Bettygene Egan, MBA
> Sr. Project Manager
> National Risk Management
> One Kaiser Plaza, 18 Bayside
> Oakland, CA 94612
> Office: (510) 271-5713  TL: 8-423-5713
> Cell: (510) 912-5148
> Fax: (510) 271-6988
>
> Administrative Support:
> Van B Nguyen - (510) 267-4892
>
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>
> From:        Harold Lehmann <lehmann at JHMI.EDU>
> To:        IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Date:        05/03/2013 06:33 AM
> Subject:        Re: checklist vs. checklist
> ------------------------------
>
>
>
> I have been thinking for a while of the concept of a "Task Guide"---where
> an authority (faculty member; a crowd) sets up the sequence of steps
> required to accomplish a task and, for each step, suggests a number of
> resources that could help the user. The classic use case is evidence-based
> medicine, where the steps are "Find appropriate guideline; find appropriate
> systematic review; search PubMed Clinical queries," etc. At each step,
> there are links, e.g., to databases of guidelines, to appraisal guides.
>
> So when I look at this list that Ross has assembled, I am thinking, can we
> assemble resources that speak to each step? They may be System 1 or System
> 2 oriented, I suppose.
>
> E.g., I can imagine a user asking, "Can you help me think of other known
> causes of this problem?" [Yes, these are differential-diagnosis lists from
> textbooks, review articles, or diagnostic decision support systems.] "Can
> you help me maintain an open mind?" [Probably the same list.] "How do I
> know when the timing is complete?" [Resources on good interview technique].
> Etc.
>
> Such a resource list yoked to good practice might provide a way of us
> projecting to the larger community what we know about overcoming barriers
> to improving diagnosis in medicine and providing direct help.
>
> Harold
>
> --
> ***************************************************************************
> Harold P. Lehmann, MD PhD
> Interim Director, Division of Health Sciences Informatics
> Johns Hopkins University School of Medicine
>
>
>
> *From: *Ross Koppel <*rkoppel at sas.upenn.edu* <rkoppel at sas.upenn.edu>>*
> Reply-To: *Society to Improve Diagnosis in Medicine <*
> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG* <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>,
> Ross Koppel <*rkoppel at sas.upenn.edu* <rkoppel at sas.upenn.edu>>*
> Date: *Thursday, May 2, 2013 9:54 PM*
> To: *"*IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG*<IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>"
> <*IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG*<IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> >*
> Subject: *checklist vs. checklist
>
> Checklist for what?
>
> A checklist for a procedure is one thing.  A check list to improve Dx is
> another.   For the procedure, you want tools, steps, etc.  Checklists are
> great.  (OK, also see Peter P's very nuanced article in Millbank Memorial
> Quarterly...maybe not so cut and dry)
>
> For Dx, on the other hand, I can imagine a checklist that's a bolus of
> difficult questions that may not improve outcomes, but rather just anger
> the clinician.  Consider the following almost absurd but not irrelevant
> questions:
>     Do you remember other known causes of this problem?
>    Have you prematurely closed inquiry?
>    Did you take enough time?
>    Have you examined the pt's history carefully enough?
>    Do you remember your pharmacology well enough?
>    Did you meet with the radiologist(s) for fully explore the ambiguities?
>    When you go into another room, do you increasingly wonder why you are
> there?
>    Are you willing to admit your ignorance?
>    Should you talk to someone else?
>    Did you do the all of the appropriate tests but none extra?
>
>
> I would suggest that some of the Dx-related questions are very different
> than asking about the availability of gloves.  More important, some are
> unlikely to get answers beyond annoyance.
>
> Ross Koppel, Ph.D. FACMI
> Sociology Dept and Sch. of Medicine
> University of Pennsylvania, Phila, PA 19104-6299
> 215 576 8221 C: 215 518 0134
> On 5/2/2013 8:37 PM, Robert L Wears, MD, MS, PhD wrote:
> Certainly it can often be used as an excuse, but the effects of
> time/production pressure are
> often more subtle and distributed.  People habituate to various
> constraints -- if they are
> often time pressured, and must sacrifice thoroughness for efficiency,
> those behavioural
> patterns tend to carry over into other instances where time pressure may
> be absent.
>
> I'd suggest reading Erik Hollnagel's book on the efficiency-thoroughness
> tradeoff.  One idea
> he brings up is that people tend to be biased to favour efficiency over
> thoroughness, and
> that this is so deeply ingrained one would suspect an evolutionary basis
> for it.  Saving a bit
> of time is not often important, but in an open system, a world with
> uncertainty, risk, and
> unexpected events in it, a bit of extra time sometimes turns out to be
> critical in dealing w/
> the unexpected.
>
> The full reference is:
>
> Hollnagel, E. (2009). *The ETTO Principle:  Efficiency-Thoroughness
> Tradeoff (Why Things That Go Right Sometimes Go Wrong)*. Farnham, UK:
> Ashgate.
>
> bob
>
> On 2 May 2013 at 3:19, Jason Maude wrote:
>
> > I initially saw my GP (very experienced and senior partner in the
> > practice) who was certainly not rushed as he even asked me about some
> > other things I had seen him with before. The x-ray was carried out at
> > the small local hospital that was attached to the practice. There was
> > no queue to get the x-ray done so I don't believe that the radiologist
> > was rushed. It was then looked at again by a couple of nurse
> > practitioners, all in the calm of a sleepy English country town
> > hospital!
> >
> > This is why I started to conclude that lack of time could often be an
> > excuse rather than a legitimate explanation. I also blamed myself for
> > too easily accepting what seemed a plausible diagnosis. I should have
> > asked "what else could it be" and acted as the trigger for more
> > thinking. The whole episode showed me what an easy trap it is to fall
> > into.
> >
> > So do we either accept this as the norm and say that nothing can be
> > done (not enough time etc)- in other words there will be an inbuilt
> > industry dx error of 10-20% - or is there a way we can force change.
> > My view, reinforced by this episode, remains that the differential (or
> > say 3 diagnoses) must be recorded in the medical notes at the time of
> > the consultation.
> >
>
> Robert L Wears, MD, MS, PhD
> University of Florida    Imperial College London
> *wears at ufl.edu* <wears at ufl.edu>            *r.wears at imperial.ac.uk*<r.wears at imperial.ac.uk>
> 1-904-244-4405 (ass't)            +44 (0)791 015 2219
> What hits the fan will not be evenly distributed.
>
>
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-- 
Peggy Zuckerman
www.peggyRCC.wordpress.com







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