Ebola in Dallas

Bob Latino blatino at RELIABILITY.COM
Wed Oct 8 12:04:59 UTC 2014


One way is if FMEA's were taken more seriously, such comprehensive 'what-if type' of analyses would be conducted on and acted on accordingly.  The Ebola situation is a classic case where a comprehensive FMEA should be performed at every hospital in the U.S. (and elsewhere for that matter).

Unfortunately, in my experience, the current TJC FMEA requirement is viewed as a formality for compliance purposes rather than an analytical tool that can actually benefit the organization and the patient.

Robert J. Latino, CEO
Reliability Center, Inc.
1.800.457.0645
blatino at reliability.com
www.reliability.com

From: Shapiro, Barbara [mailto:Barbara.Shapiro at UHHOSPITALS.ORG]
Sent: Wednesday, October 08, 2014 7:43 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Ebola in Dallas

You are correct. But so far society has shown us that nobody is willing to give us the resources we really need. It's cost benefit. What more needs to happen before society wakes up and we, as physicians, start getting the resources we need. I'm guessing the ER docs in Texas just didn't have the time to think through the situation - they certainly knew this was a febrile man who had just come from Liberia - my ten year old would have figured this out! But in the busy, crazy fog of the ER, they basically missed it.


Barbara E. Shapiro, M.D.,Ph.D.
University Hospitals Case Medical Center



From: David Meyers
Sent: 10/7/14, 8:18 PM
To: Society to Improve Diagnosis in Medicine
Subject: Re: [IMPROVEDX] Ebola in Dallas
In the end, some type of analysis of the facts will get at many of the contributing causes and corrections in the Dallas ebola case - knowledge deficits, failure to recognize the pattern, EHR issues, biases which always figure in decision-making, additional training, implementing protocols, etc.  But suppose a contributing factor IS the busy, harried, distracted ED staff who didn't have time to put all of the info together and make the right decision after thinking carefully about it, and instead acted as best they could under the circumstances - what Bob Wears has called the "tragedy of adaptability".  This is a recurring theme in a lot of diagnostic and other medical errors.  Are we, and more importantly the hospital CEO/CFOs and health insurers and maybe ultimately society prepared to make and pay for changes such as additional staff, more useful EHRs and other resources or the radical restructuring of clinical work which may be needed to fix these problems.  Perhaps the IOM will address this in their report on diagnostic error next year.

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