Fishbone RCA of Dallas Case.............FW: Ebola in Dallas

Kuhn, Gloria gkuhn at MED.WAYNE.EDU
Wed Oct 8 12:16:04 UTC 2014


I think the check list of questions pertaining to history is vital both for the triage nurse and doctor.  I think the failsafe, if there is one, is for the doctor to ask the questions also and not rely on either the nurse or the system.  It is just faster and you don’t make any assumptions.
Gloria Kuhn

From: Karen Cosby [mailto:kcosby40 at GMAIL.COM]
Sent: Tuesday, October 07, 2014 8:52 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Fishbone RCA of Dallas Case.............FW: Ebola in Dallas

If it helps the cdc has issued guidelines and alerts. I know we have a policy and are on edge waiting for the first case. If it's anything like the anthrax scare we will prob now be deluged with false alarms and still risk missing the next case. Contrary to expectations it  may come in some unexpected form such as  a white college aged kid who just visited or traveled through the area

Sent from my iPhone

On Oct 7, 2014, at 8:41 AM, Ruth Ryan <rryan at LAMMICO.COM<mailto:rryan at LAMMICO.COM>> wrote:
On blame versus improvement:

It might be a useful exercise, acknowledging not all is known, to use our systematic RCA approach.

Diagram the contributing causes, including

1.      Cognitive (Denial: “I can’t possibly be seeing the 1st case of Ebola in the US”)

2.      System-related (Crowded Saturday night ER; Some failure in taking/communicating the history, how could this be made fail safe going forward?)

3.      Patient related (Pt’s relative disclosed he had come from W Africa but pt denied being around anyone sick)

4.      No fault (1st case in US)

Key for everyone is a protocol going forward. Do we have that, and how is it being taught? Is it disseminated to MD offices, clinics as well as ERs?

Ruth
Ruth Ryan RN, BSN, MSW, CPHRM
Senior Risk Management Education Specialist
LAMMICO
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From: robert bell [mailto:rmsbell at ESEDONA.NET]
Sent: Monday, October 06, 2014 12:41 AM
Subject: Re: Ebola in Dallas

Yes, a great case for focussing on the issues of diagnosis.

I wonder how many second or third visits to the ER occur with incorrect/missed diagnoses.

These figures would be interesting.

Rob
On Oct 5, 2014, at 5:43 PM, Joe Graedon <jgraedon at gmail.com<mailto:jgraedon at gmail.com>> wrote:



Guessing a very busy ER and a harried MD made a quick decision that turned out to be wrong.

Here is our take on the passing of the buck:

http://www.peoplespharmacy.com/2014/10/04/delayed-diagnosis-of-ebola-in-dallas-reveals-fundamental-flaws/

Joe Graedon

On Oct 5, 2014, at 6:31 PM, David L Meyers <dm0015 at ICLOUD.COM<mailto: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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