Error Rates: Diagnosis vs Delivery of Care

Amy Reinert amy.reinert at GMAIL.COM
Wed Dec 11 20:15:45 UTC 2013

I know it has been stated before, but Bob's message inspired me to
reiterate that there are potential weak links in the diagnostic system
other than physician error or patient behavior.

Case in point: This morning I went to the lab for some tests ordered by a
specialist. One of them required a baseline blood reading, drinking a
liquid, and another blood draw hours later. It was very early in the
morning, so I was the first patient. The hospital had just implemented
new equipment and systems, and so the lab techs were using new devices. The
woman conducting my test became extremely frustrated when her badge ID#
would not be recognized by the new device, as required for her to proceed
with my baseline reading. Although she was in another room as she tried to
log onto the device, I could clearly hear her escalating frustration. She
asked a colleague for help, then a few minutes later loudly proclaimed,
"well, if they are not going to set me up properly to do my job, then
they'll just have to deal with it. I'm just going to give her the drink."
She then approached me with the liquid I had to drink and told me to drink
it, then she would start timing for my next blood draw. Having had the
procedure before, I knew the importance of the baseline reading, and asked
her about it. She responded that she would just have whomever processed my
other tests run the baseline, too. She was a bit vague about how that was
going to happen, so I pushed her on it, and asked if she was certain the
results would be accurate-- would a baseline reading ever occur-- if she
worked outside the hospital system. She hesitated, then called a supervisor
for an over-riding access code. Eventually, she did the procedure
correctly. However, she was perfectly willing to by-pass an important step
due to her frustration that her equipment was not working well. For me,
that could have meant an inaccurate result, leading my doctor to an
inaccurate diagnosis; or, the inconvenience and expense of having to repeat
the test.

Yes, this lab tech was unprofessional and probably needs to work elsewhere.
However, either her equipment was faulty, or the data entry for use of it
was incomplete. Certainly the tech handled the situation poorly, but the
equipment, the IT department or other programming person, might also share
burden of responsibility for the breakdown leading to a possible
misdiagnosis. None of these things had anything to do with me, nor my
excellent specialist. I think it is important to include hospital systems
and ancillary care providers in research into rates of misdiagnosis.

All the best--
Amy Ruzicka, Ph.D.

On Wed, Dec 11, 2013 at 1:17 PM, Robert J. Latino
<blatino at>wrote:

> I am new to this forum and in search of studies related to specific error
> rates.  I have not been able to find such credible studies on other forums.
>  I am a career lead investigator specializing in understanding the
> reasoning behind decision-making that results in undesirable outcomes.
> I am seeking any studies related to making the distinction between the
> rate of making diagnostic/clinical decision errors versus decision errors
> in the execution of the delivery of care (after an accurate diagnostic or
> clinical judgment call).
> When a bad outcome occurs, what % of the time is it attributed to a
> diagnosis error as opposed to the % of time it is attributed to a patient
> care error occurring after an accurate diagnosis?
> While these appear in my inquiry as mutually exclusive ('OR' statements),
> it is understood that they certain do occur together as well ('AND'
> statement) to produce the bad outcome.
> Any guidance would be greatly appreciated.
> Bob Latino
> Robert (Bob) J. Latino
> Reliability Center, Inc., P.O. Box 1421, Hopewell, VA  23860
> (O) 804.458.0645  (F) 804.452.2119
> blatino at l
> Moderator: Lorri Zipperer Lorri at, Communication co-chair, Society
> for Improving Diagnosis in Medicine
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