Higher error in certain groups?

Bunting, Silvia Silvia.Bunting at CHOA.ORG
Tue Sep 30 19:18:06 UTC 2014


While we all agree that we need hard data, we could also advocate for culture change.  I believe the One Is not Zero is a worthy cause, the focus is mostly on system error, rather than cognitive error. As many scholars have pointed out, the critical thinking should be a part of a medical professional’s life-long learning experience, starting from medical school to the yearly CME activities.  I am glad to know that society is working on all of these.

From: Ross Koppel [mailto:rkoppel at SAS.UPENN.EDU]
Sent: Monday, September 29, 2014 9:03 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Higher error in certain groups?

Rob,     You are making two points....and I'm not sure either disagrees with anything I said.

1. We need the numbers.  All agree.  I would add that:

    We are probably missing 98% of medication errors.
    We have excellent data on wrong site surgery and wrong patient surgery
    We have terrible data on wrong patient errors involving meds....for prescribing, dispensing and administration
    We have bad data on Dx errors.... but at least one can get a sort of handle on them if one follows the trajectory of the patient over a long time.
But, yes, we need the numbers and they are hard to get.

2. Your observations of errors you notice with any of your contacts with the medical profession:  I argue that the errors you observe -- while apparently quite high -- are much lower than what the average patient undergoes.  On the most trivial level, you are literate and you speak English.  On a higher level, they know you're a doc and don't want to screw up.  Most patients, even if we gave them a digital recorder, would be unable to identify the vast majority of errors to which they are subjected.

Heck, I wrote one of the major papers on workarounds to barcode medication admin.   Last month I was in the hospital ED for a bad dog attack.  They gave me the wrist band of a Mr. Thomas Keller, born 1977  (may have been 1971.... I can't remember).

If you are saying you see many errors all the time:  Then yes, absolutely.  If you are saying Docs face more errors than the avg patient, then I disagree.

NOTE:  Many, Many errors are caught and stopped before they harm patients.  And much of the harm that does get through is low level.

Ross



Ross Koppel, Ph.D. FACMI

Sociology Dept and Sch. of Medicine

Senior Fellow, LDI, Wharton

University of Pennsylvania, Phila, PA 19104-6299

215 576 8221 C: 215 518 0134
On 9/29/2014 8:10 PM, Robert Bell wrote:
Ross, that has not been my general experience over 40 years. But I have no way of proving it.

There is hardly a contact that I have with the medical profession that is not associated with some big or small problem, be it the wrong doctor's name on a urine specimen, lack of communication in a doctor's office (telling the staff you are there in the waiting room) being given someone else's paperwork for labwork, having crossed leads on an EKG read by the physician as normal, surgery that has unexpected negative results, or missed serious diagnoses, etc. And yes, many good things have happened.


Prior to a talk I gave to staff at a local hospital, I collected my own errors in every day life that I made. My definition of an error was something that truly annoyed me. Like leaving my car keys in the house when jumping into the car in the garage, or doing four shopping tasks but forgetting the fifth. I seem to remember that on one day I had 8, and the next day 6 such events.


Keeping a list of errors, both small and large, that happen with each personal medical contact might be valuable!


That is why the 440,000 figure for annual deaths, for me, could well be correct.


But in all of this Ross, we need good figures, not guesses.


How do we get that information? Can we move very far forward without it?


Rob Bell, M.D.

Sent from my iPad

On Sep 29, 2014, at 5:40 AM, Ross Koppel <rkoppel at SAS.UPENN.EDU<mailto:rkoppel at SAS.UPENN.EDU>> wrote:
My guess is that health care professionals get better and safer care than most patients, in general.  The perceived "higher rates" of errors are a reflection of health care professionals ability to notice errors that occur to many patients.




Ross Koppel, Ph.D. FACMI

Sociology Dept and Sch. of Medicine

Senior Fellow, LDI, Wharton

University of Pennsylvania, Phila, PA 19104-6299

215 576 8221 C: 215 518 0134
On 9/28/2014 6:07 PM, Hoffer, Edward P.,M.D. wrote:

Anecdotes abound - doctors and nurses caring for health care professionals, particularly those they know and/or who work at their institution, often cut corners or avoid unpleasant procedures. While this is intended as kindness, it often means appropriate care is withheld.



Whether anecdotes truly reflect reality, I have no way of knowing.



Ed



Edward P Hoffer MD, FACP



________________________________________

From: Teresa Graedon [terry.graedon at GMAIL.COM<mailto:terry.graedon at GMAIL.COM>]

Sent: Sunday, September 28, 2014 9:30 AM

To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>

Subject: Re: [IMPROVEDX] Higher error in certain groups?



Robert,



That is an interesting idea. How would it work?



I suspect that HCPs are simply more likely to detect errors than less (health-care-) educated patients. I'd be interested in data, though, or a plan to gather the evidence.



Terry Graedon, PhD

The People's Pharmacy



On Sep 26, 2014, at 10:46 PM, Robert Bell <<mailto:rmsbell at ESEDONA.NET>rmsbell at ESEDONA.NET<mailto:rmsbell at ESEDONA.NET>> wrote:



I have the idea that HCPs, particularly physicians, are more like to be exposed to errors in medicine when they are patients.



Is there any truth to this and, also are there other groups of patients that are more likely to be involved in errors when patients?



Rob Bell, M.D.



Sent from my iPad

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