Another argument for patient's access to their test results

Hamm, Robert M. (HSC) Robert-Hamm at OUHSC.EDU
Mon Apr 21 16:00:37 UTC 2014


Overwhelmed with work. Still there is an important distinction between “overwhelmed with work and so fails to notice something” and “overwhelmed with work and so chooses not to do something”. Perhaps there should be a “Fuck this job” button and whenever somebody slams it, someone comes in non-punitively to make the system work. It is a sign of a failure of management (allocating tasks and responsibilities to people psychologically capable of handling at the moment), as well as of failure on the part of the worker.

From: Robert Bell [mailto:rmsbell at ESEDONA.NET]
Sent: Monday, April 21, 2014 9:48 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Another argument for patient's access to their test results

I see the report says that the technologists motivation was that she was overwhelmed with work. One of the standard causes to the background of many errors in medicine.

Rob Bell

Sent from my iPad

On Apr 21, 2014, at 6:39 AM, Leonard Berlin <lberlin at LIVE.COM<mailto:lberlin at LIVE.COM>> wrote:
Mark,

There is no question that the technologists's actions were far worse than negligent -- they were blatantly criminal.  I cannot figure out how the mammography facility (I'm not sure whether it's a hospital or not) allowed this to happen.  A radiologist is required to interpret every mammogram, but in this case it appears (although available facts are vague) that the tech herself routinely classified these mammograms as "normal," without a radiologist ever seeing them.  Federal  law mandates that mammography facilities send to every patient who has undergone a mammography exam a summary  written in lay language of her mammographic report.  I presume that the 1000-plus women received letters stating their mammograms were normal.  Indeed, a terrible situation!  It is inexcusable that the facility had so little oversight and supervision that it allowed a situation like this to occur.

Lenny


Leonard Berlin, MD, FACR
Radiology department, Skokie Hospital
Skokie, IL;
Professor of Radiology
Rush University, and
University of Illinois
Chicago, IL

> Date: Sun, 20 Apr 2014 23:02:50 -0400
> From: Mark.Graber at VA.GOV<mailto:Mark.Graber at VA.GOV>
> Subject: [IMPROVEDX] Another argument for patient's access to their test results
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>
> In a very disturbing story this week, a radiology tech was accused of notifying 1000+ women that their mammagrams were normal, although she didn't know this to be true, and some in fact were not. http://www.today.com/video/today/54989210#54989210
>
> Its my understanding that all women are supposed to receive a copy of their test result, and its not exactly clear from this report if the tech just gave women a verbal 'ok', or if she actually altered the radiologist's report. This is a class of diagnostic error I've never encountered before, but I'm hoping that the directly-mailed results mitigated the tech's false assurances. If anyone has access to more facts on this case, I'd be interested to hear them.
>
>
> Mark L Graber, MD FACP
> Senior Fellow, RTI International
> Professor Emeritus, SUNY Stony Brook School of Medicine
> Founder and President, Society to Improve Diagnosis in Medicine
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