Ebola in Dallas

Amy Reinert amy.reinert at GMAIL.COM
Mon Oct 6 21:26:38 UTC 2014


With deepest respect, Karen (and everyone else), I wonder if you might
elaborate on what you believe the bigger lessons are that we might take
from this. Would you care to say more?

Generally speaking, although finger-pointing and blame gaming are
obstructive in investigative processes, unwillingness to hold individuals
accountable for errors, coupled with reluctance to name things what they
are, create collective environments where quality is reduced rather than
improved. If diagnostic accuracy is to improve, both analysis of systems
and individual accountability for actions and errors must occur. I think
this is true in this instance of communication failure, as well as every
other case of misdiagnosis out there. There are a great many points at
which a system can break down. Those points include particular elements of
system and process, as well as every single human being involved in it. It
isn't helpful to rush to judgement, but when lives are at stake, we cannot
afford to be timid in our candor.

Regards,

Amy Ruzicka, Ph.D.

On Monday, October 6, 2014, Karen Cosby <kcosby40 at gmail.com> wrote:

> How strange to follow this thread.  I thought we had grown past the
> tendency to blame and shame each other.  I don't think any of us know all
> the first hand details, yet we are quick to blame, and quick to take
> offense.  There are bigger lessons to take from this.  And it will require
> more than snap judgments to fix the real issues that are in such need of
> solutions.
>
> On Mon, Oct 6, 2014 at 10:30 AM, Alan Morris <Alan.Morris at imail.org
> <javascript:_e(%7B%7D,'cvml','Alan.Morris at imail.org');>> wrote:
>
>> As I have mentioned before, this is an example of the value of detailed
>> computer decision-support tools.  Once data are acquired (by RN, MD,
>> Patient with and iPone or iPad, telephoneĊ ) they can drive rules.  This is
>> clearly feasible across disciplines and cultures, but scalability is not
>> yet tested.
>>
>> Alan H. Morris, M.D.
>> Professor of Medicine
>> Adjunct Prof. of Medical Informatics
>> University of Utah
>>
>> Director of Research
>> Pulmonary/Critical Care Division
>> Sorenson Heart & Lung Center - 6th Floor
>> Intermountain Medical Center
>> 5121 South Cottonwood Street
>> Murray, Utah  84157-7000, USA
>>
>> Office Phone: 801-507-4603
>> Mobile Phone: 801-718-1283
>> Fax: 801-507-4699
>> e-mail: alan.morris at imail.org
>> <javascript:_e(%7B%7D,'cvml','alan.morris at imail.org');>
>> e-mail: alanhmorris at gmail.com
>> <javascript:_e(%7B%7D,'cvml','alanhmorris at gmail.com');>
>>
>>
>>
>>
>>
>>
>>
>>
>> On 10/5/14, 4:31 PM, "David L Meyers" <dm0015 at ICLOUD.COM
>> <javascript:_e(%7B%7D,'cvml','dm0015 at ICLOUD.COM');>> wrote:
>>
>> >It appears that the cause of improving diagnosis in medicine was given an
>> >unfortunate boost in Dallas this week with the (mis)handling of the
>> >nation's first case of ebola both at the clinical and public health
>> >levels, that is already having risk management and public policy effects.
>> > With respect to the actual care of the patient, who was not diagnosed
>> >until his second ED visit several days after his first one to the same
>> >ED, the full story remains to be elucidated, but we've witnessed the
>> >painful release of information followed by corrections and restatements
>> >that too often characterize events of this sort.
>> >
>> >Initially, a nurse seemed to be the culprit blamed for obtaining critical
>> >information about travel history from the Liberian patient recently
>> >arrived in Dallas from Lagos via Brussels and Washington and not passing
>> >it on the health care team or following the CDC guidelines for handling
>> >such patients, said to be in place at the hospital.  Next, blame focused
>> >on the failure of the EHR to properly communicate information between the
>> >nurse and subsequent providers including the treating physician. The
>> >latest information seems to be that the physician had the information and
>> >made a wrong decision regarding diagnosis, management and disposition;
>> >whether s/he acquired relevant history independently or from the EHR is
>> >not clear.
>> >
>> >More information and analysis is trickling in and it will be sometime
>> >before most of the facts are known, but it is clear there were human
>> >errors and system errors which contributed to the situation. This may
>> >wind up being the most studied case of diagnostic error to date with the
>> >greatest potential to alter how the public sees this problem.  I imagine
>> >the IOM committee now addressing this subject will have some very
>> >instructive material to work with.  Root cause analysis anyone?
>> >
>> >Here's a chronicle of the events as pieced together by the Dallas Morning
>> >News.  Interesting reading.
>> >
>> http://www.dallasnews.com/news/metro/20141004-dallas-ebola-case-shows-even
>> >-sound-plans-can-fail-spectacularly.ece
>> >
>> >To unsubscribe from the IMPROVEDX:
>> >mail to:IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
>> <javascript:_e(%7B%7D,'cvml','to:IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG');>
>> >or click the following link: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>> <javascript:_e(%7B%7D,'cvml','IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG');>
>> >
>> >Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>> <javascript:_e(%7B%7D,'cvml','IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG');>
>> >
>> >For additional information and subscription commands, visit:
>> >http://www.lsoft.com/resources/faq.asp#4A
>> >
>> >http://LIST.IMPROVEDIAGNOSIS.ORG/ (with your password)
>> >
>> >Visit the searchable archives or adjust your subscription at:
>> >http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX
>> >
>> >Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair,
>> Society
>> >for Improving Diagnosis in Medicine
>> >
>> >To unsubscribe from the IMPROVEDX list, click the following link:<br>
>> ><a
>> >href="
>> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPRO
>> >VEDX&A=1"
>> >target="_blank">
>> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SU
>> >BED1=IMPROVEDX&A=1</a>
>> ></p>
>>
>> To unsubscribe from the IMPROVEDX:
>> mail to:IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
>> <javascript:_e(%7B%7D,'cvml','to:IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG');>
>> or click the following link: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>> <javascript:_e(%7B%7D,'cvml','IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG');>
>>
>> <javascript:_e(%7B%7D,'cvml','IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG');>
>>
>>
>>
>>
>> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair,
>> Society for Improving Diagnosis in Medicine
>>
>> To unsubscribe from the IMPROVEDX list, click the following link:<br>
>> <a href="
>> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1"
>> target="_blank">
>> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
>> </a>
>> </p>
>>
>
>
> ------------------------------
>
> <javascript:_e(%7B%7D,'cvml','IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG');>
>
> To unsubscribe from IMPROVEDX: click the following link:
>
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
> <javascript:_e(%7B%7D,'cvml','IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG');>
>
> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society
> for Improving Diagnosis in Medicine
>
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/








HTML Version:
URL: <../attachments/20141006/f2f78f8b/attachment.html>


More information about the Test mailing list