Another argument for patient's access to their test results

Vic Nicholls nichollsvi2 at GMAIL.COM
Tue Apr 22 15:39:26 UTC 2014


I saw a much beloved doctor get "speared" when management needed a "fall 
guy". The problem is getting management/admin to take responsibility 
because there is where the issue lies.

I've seen some doctors that you can tell the issue is their management, 
the culture.

Victoria


On 4/22/2014 11:08 AM, Bob Latino wrote:
>
> 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
>
> Royal Australasian College of Surgeons
>
> PO Box 7476 East Brisbane QLD 4169 Australia
>
> t: +61 7 3249 2903  |  m: +61 0488 585 301 f: +61 3 9249 1217
>
> www.surgeons.org <http://www.surgeons.org/>
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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
> MARK.GRABER at IMPROVEDIAGNOSIS.ORG <mailto:MARK.GRABER at IMPROVEDIAGNOSIS.ORG>
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