Higher error in certain groups? II

Ross Koppel rkoppel at SAS.UPENN.EDU
Wed Oct 1 04:10:08 UTC 2014


Follow up to previous email

I forgot to mention why the orders were stopped  (and remember this is a 
teaching hospital):

pharmacists called the young docs
senior docs or colleagues questioned them
nurses questioned them
they thought about it some more
they got a lab or other result that suggested another 
approach/idea/drug.   (Note about this one:  We hypothesized that 
older/more experienced docs would not be so quick to order if they knew 
a lab result was coming.  We've never fully studied that hy, but every 
more experienced doc we discussed it with loved the hy).

Note:  We did not count orders stopped within one minute or so. That was 
the fat finger grace period.

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 9/30/2014 5:20 PM, Robert Bell wrote:
> Following up on Ross' comments, coud I ask members of the list, what 
> are the top three things each would like to see happen to 
> significantly reduce the deaths and injury that occur with medical 
> errors (including diagnostic). I have the idea that having a priority 
> ranked shopping list of the agreed upon things to start doing would 
> advance the discussion from where it currently rests.
>
> Most seem to agree that we are not making much progress. How can we 
> change this?
>
> Robert Bell, M.D.
>
>
>
>
> ------------------------------------------------------------------------
> *From: * Ross Koppel <rkoppel at SAS.UPENN.EDU>;
> *To: * <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>;
> *Subject: * Re: [IMPROVEDX] Higher error in certain groups?
> *Sent: * Tue, Sep 30, 2014 1:03:15 AM
>
> 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 
>> <javascript:return>> 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  <javascript:return>]
>>>> Sent: Sunday, September 28, 2014 9:30 AM
>>>> To:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG  <javascript:return>
>>>> 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<rmsbell at ESEDONA.NET  <javascript:return>> 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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