Another argument for patient's access to their test results

Bob Latino blatino at RELIABILITY.COM
Tue Apr 22 15:08:01 UTC 2014


To add to Gervais questions:

j. Had she taken this action before (using Physicians PIN for such purposes) without consequence?
k. Have others in the same position taken this action before without consequence?

Oftentimes such acts have become 'normal practice' over time and the beginning of normalization of deviance sets in.  Left unchecked (as Gervais is asking about), the action/shortcut taken is considered acceptable.  "I took a shortcut and nothing bad happened so therefore I have a new normal".  Most anyone under time pressure will take such shortcuts by skipping steps in a sequence.

The hypocrisy of these situations is to discipline only the decision-maker and only when a failure occurs.  The real infraction was the behavior itself under conditions when there was no failure and management failed to identify the behavior as unacceptable.

Robert J. Latino, CEO
Reliability Center, Inc.
1.800.457.0645
blatino at reliability.com
www.reliability.com

From: Wansaicheong Gervais Khin-Lin (TTSH) [mailto:gervais_wansaicheong at TTSH.COM.SG]
Sent: Tuesday, April 22, 2014 10:47 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Another argument for patient's access to their test results

Dear All,

Let’s use the video as a starting point.

I’ve watched the video a few times and this was said at about 29 to 40 seconds. (I may be incorrect in the exact words).

The technician used a physician’s PIN code to access hospital computers to create reports that repeated the same story of no cancer that she had told to the patients.

Let’s also assume the video has been truthful. I am aware that this assumption may not be true. It leads to a few thoughts


a.       There is no typo. No simple mistake. No ‘I accidentally did this.’ She did this 1289 times.

b.      Her mitigation (because she pled guilty) is that she was over worked. I have a visceral bias against this as an adequate explanation. If she had just ‘burnt’ or ‘hidden’ the work, I would understand. How does her action reduce the ‘overwork’? It seems illogical unless it is offered just as an excuse.

I feel that there are system issues at play but am curious about the following:


a.       How did no one notice that she was this far off the reservation?

b.      Did she have adequate supervision and mentoring by the organisation?

c.       Did she have a way to verbalise her concerns to her supervisor?

d.      Why does she have the physician’s PIN code?

e.      What is the security policy at the hospital?

f.        Were people trained and briefed about accountability?

g.       Is it true that the technicians are over worked?

h.      What were her work hours like?

i.         What would her peers be expected to do if placed in the same environment?

I am not convinced that there is a misdiagnosis here that is easily pigeon holed into the existing framework of cognitive errors and bias.
The role of the truly malign is not something that we like to think about but has to be one that we consider if we are truly holistic in approaching misdiagnosis.

Gervais



From: Therese Rey-Conde [mailto:Therese.Rey-Conde at SURGEONS.ORG]
Sent: Tuesday, 22 April 2014 8:46 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Another argument for patient's access to their test results

I wonder if the group is reading too much into this dreadful mistake. Isn’t it possible it was a simple “typo” i.e. the technologist pushed the “reply all” button or something similar, in error?

We’ve all been caught in that trap that at least once.

Systems should be set up in organisations to prevent this from occurring.

Therese Rey-Conde MPH



Therese Rey-Conde
Queensland Audit of Surgical Mortality Project Manager
Northern Territory Audit of Surgical Mortality Project Manager





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From: Peggy Zuckerman [mailto:peggyzuckerman at GMAIL.COM]
Sent: Tuesday, 22 April 2014 2:18 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Another argument for patient's access to their test results

Quite similar to this is the very frequent situation in which a patient is told re the blood labs, "We'll call if there is a problem; otherwise, don't expect to hear from us".  Stats indicate that some 15-18% of labs with abnormalities are not reported to patients.  With the millions of tests done, that percentage reveals a tremendous weakness in our system, and another reason to be pro-active in getting and reviewing one's own labs.
Moreover, that statistic does not indicate whether the reported problems suggested by the abnormal labs ever trigger the proper follow up, not to mention are used efficiently in the diagnosis.  Case in point:  a PSA test is higher than normal, and patient is told to see specialist.  Is there a formal referral, are the abnormal labs provided to the new specialist, are new labs prescibed, does the GP inform expect and prepare for a response from the specialist?  No stats on any of that, which are certainly "delayed diagnosis" incidents.
If these labs and the value of them were EXPLAINED to patients, so that they understood the importance of the abnormal reading, more appropriate follow up by both patient and doctor would happen.

Peggy Zuckerman

On Sun, Apr 20, 2014 at 8:02 PM, Graber, Mark <Mark.Graber at va.gov<mailto:Mark.Graber at va.gov>> wrote:
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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