Checking errors (was checklist vs checklist)

Brian Goldman brian.goldman at CBC.CA
Sat May 4 00:36:41 UTC 2013


Pharmacists and pharm techs no longer stand beside one another confirming
each others calculations.  That process is fraught with cognitive bias.
Friends and colleagues tend to agree with one another's calculations
because of bias.  The proper way to review calculations is to have two
parties do so independently of one another.


On Fri, May 3, 2013 at 1:18 PM, robert bell <rmsbell at esedona.net> wrote:

> 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 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.
>>
>>
>>
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-- 
Brian Goldman
Host, White Coat, Black Art
CBC Radio One
416-205-2375 - phone
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