Checking errors (was checklist vs checklist)

Dr.Will dr.will at FUSE.NET
Fri May 3 17:55:13 UTC 2013

Yes that is precisely why my patients (and I agree) say "do not send me to
the hospital, as some adverse event will occur". Hopefully not a sentinel

Will Sawyer, MD



From: robert bell [mailto:rmsbell at ESEDONA.NET] 
Sent: Friday, May 03, 2013 1:18 PM
Subject: Checking errors (was checklist vs checklist)


Thanks Peggy Z.


Interesting, not unlike the errors when one person checks the others work
(e.g. blood checking systems) - the second person makes the same error as
the first - ? about 5% of the time believing the first person is correct. ?
not properly checking because of trust, or time restraints, or other issues.


How do you overcome this kind of error?


Should there be a culture of trusting no one in medicine?!


Rob Bell


On May 3, 2013, at 9:12 AM, Peggy Zuckerman wrote:

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

Peggy Z


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


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