Ebola in Dallas

BRIAN GOLDMAN drhbg at ROGERS.COM
Mon Oct 6 21:31:42 UTC 2014


I just got off the phone with Lauren Silverman of NPR in Dallas.  You'll be happy to know I have set her straight on the virtues of root causes analysis instead of the blame game.  

Brian
 
Brian Goldman, MD, MCFP(EM), FACEP
Mount Sinai Hospital, Room 206
600 University Avenue
Toronto, ON M5G 1X5
416-822-5044 phone
416-586-4719 fax


On Monday, October 6, 2014 5:25 PM, Peggy Zuckerman <peggyzuckerman at GMAIL.COM> wrote:
 


I agree that the issue of blame is not helpful, but the details as to where the system failed to pick up and transmit information will naturally have to involve people, record-taking-translating-transmitting-reading, operational errors and more.  Since there can be mistakes and omissions in many steps along the way, there have to be duplications of information, and way to winnow out the urgent issues.

For example, if any intake system can be updated to collect Ebola/West Africa/Liberia data from this patient and and from the critical health alerts (that I would hope exist through the US)at any one time, and be able to change to reflect a measles outbreak in a neighboring state or school district, then those alerts would have value at all times. Doctor/nurse/patient/caregiver input is part of all of that, as should be data from the CDC, the state and county health systems. That may be built-in information that is not of high value at one time, but must rise to the surface at another time.  

Peggy Z



On Mon, Oct 6, 2014 at 1:43 PM, 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> 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
>>e-mail: alanhmorris at gmail.com
>>
>>
>>
>>
>>
>>
>>
>>
>>
>>On 10/5/14, 4:31 PM, "David L Meyers" <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
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-- 
Peggy Zuckerman
www.peggyRCC.wordpress.com

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