Ebola in Dallas

Pauker, Stephen SPauker at TUFTSMEDICALCENTER.ORG
Tue Oct 7 04:23:37 UTC 2014


exactly
fix the system
 
 
 
Stephen G. Pauker, MD, MACP, FACC, ABMH
Professor of Medicine and Psychiatry
===========================
Please note new email address;
spauker at tuftsmedicalcenter.org
===========================

________________________________

From: Karen Cosby [mailto:kcosby40 at GMAIL.COM]
Sent: Mon 10/6/2014 4:43 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Ebola in Dallas


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, telephoneS) 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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