[EXTERNAL] Re: [IMPROVEDX] Ebola in Dallas

Anderson, Timothy M. CMOVAMC Timothy.Anderson at VA.GOV
Tue Oct 7 13:19:12 UTC 2014


I think the bigger question (system based rather than blaming the team for not asking proper question) is how come the recommended CDC screening questions have not been systematically distributed to medical centers around the country. How is CDC confirming screening questions have been received and implemented?

 

Same question regarding the CDC EMS checklist? http://www.cdc.gov/vhf/ebola/pdf/ems-checklist-ebola-preparedness.pdf

 

 

From: Amy Reinert [mailto:amy.reinert at GMAIL.COM] 
Sent: Monday, October 06, 2014 4:27 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: [EXTERNAL] Re: [IMPROVEDX] Ebola in Dallas

 

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
>
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