Checking errors (was checklist vs checklist)

Ross Koppel rkoppel at SAS.UPENN.EDU
Fri May 3 23:56:36 UTC 2013


I was going to comment on Rob Bell's line:

"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."

But I assumed since he's bright, trustworthy, and thoughtful, so I'd 
just say, "of course."

Ross


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 5/3/2013 1:55 PM, Dr.Will wrote:
>
> 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 event.
>
> Will Sawyer, MD
>
> ------------------------------------------------------------------------
>
> *From:*robert bell [mailto:rmsbell at ESEDONA.NET]
> *Sent:* Friday, May 03, 2013 1:18 PM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Checking errors (was checklist vs checklist)
>
> Thanks Peggy Z.
>
> I
>
> 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 discard!
>
> Peggy Z
>
> On Fri, May 3, 2013 at 8:02 AM, <Bettygene.Egan at kp.org 
> <mailto: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.
>
>
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> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, 
> Society for Improving Diagnosis in Medicine
>
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> Save the date: Diagnostic Error in Medicine 2013. September 22-25, 
> 2013 in Chicago, IL.
> http://www.dem2013.org 








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