Small things

Robert Bell rmsbell200 at YAHOO.COM
Tue Jun 9 01:55:54 UTC 2015


Does the Swiss cheese phenomenon have a place?  If so would that suggest that many errors are all different.
Rob Bell
      From: Dwight Oxley <oxley.dwight at GMAIL.COM>
 To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG 
 Sent: Monday, June 8, 2015 12:58 PM
 Subject: Re: [IMPROVEDX] Small things
   
My private practice pathology group, and a few others, recorded and reviewed even the most trivial errors. This was based on the theory that errors, serious and not, have similar root causes. Has anyone studied this theory in a definitive way?

Dwight Oxley
> On Jun 8, 2015, at 2:13 PM, Maureen Cahill <MCahill at NCSBN.ORG> wrote:
> 
> That seems a logical, possible course of action...small things occur with enough frequency that the 'reminder' is there.
> Maureen
> 
> Maureen Cahill [Associate] 312.525.3646 (D) mcahill at ncsbn.org
> National Council of State Boards of Nursing (NCSBN) 111 E. Wacker Drive, Ste 2900, Chicago, IL 60601-4277 312.279.1032 (F) www.ncsbn.org
> Our Mission – NCSBN, Leading in nursing regulation
> 
> -----Original Message-----
> From: robert bell [mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG]
> Sent: Monday, June 8, 2015 1:08 PM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: [IMPROVEDX] Small things
> 
> Would it be worthwhile focusing on the small things occurring in both hospitals and doctor’s offices to reduce standard errors and also those in diagnosis?
> 
> I seem to remember some years ago in New York and New Orleans the police focussed on the small infractions and the incidence of bigger crimes diminished.
> 
> Would rules/recommendations/standards from a respected organization about the small things reduce bigger errors?
> 
> Rob Bell, M.D.
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