Doctors Company Foundation Grant - Great News

Bruno, Michael mbruno at HMC.PSU.EDU
Tue Jun 23 14:05:54 UTC 2015

Hi Bob,

In her excellent book "Being Wrong: Adventures in the Margins of Error," Katheryn Schulz explores this very question.  She points out that, when one is actively in the process of making a mistake, being wrong feels exactly the same as being right does!

They have used copies available on for as little as $ 0.04 - well worth the investment!


Two Reviews:

"Both wise and clever, full of fun and surprise about a topic so central to our lives that we almost never even think about it."
-Bill McKibben, author of Earth: Making a Life on a Tough New Planet

In the tradition of The Wisdom of Crowds and Predictably Irrational comesBeing Wrong, an illuminating exploration of what it means to be in error, and why homo sapiens tend to tacitly assume (or loudly insist) that they are right about most everything. Kathryn Schulz, editor of Grist magazine, argues that error is the fundamental human condition and should be celebrated as such. Guiding the reader through the history and psychology of error, from Socrates to Alan Greenspan, Being Wrong will change the way you perceive screw-ups, both of the mammoth and daily variety, forever.

-----Original Message-----
From: Robert L Wears, MD, MS, PhD [mailto:wears at UFL.EDU]
Sent: Monday, June 22, 2015 7:22 PM
Subject: Re: [IMPROVEDX] Doctors Company Foundation Grant - Great News

Even worse ...

how is the cognitive state of someone acting in what later is determined to be an 'error'

different from that of someone doing normal work in a complex setting?

I don't think framing diagnostic failures (which certainly occur) in terms of 'error' (determined after the fact) is a constructive approach.


On 22 Jun 2015 at 9:06, Ross Koppel wrote:

> But, but, but....


> Most errors are unknown and very hard to discover.  Many errors are

> never discovered....ever.


> While I love the design.... the limitations must be acknowledged!


> --

> Ross Koppel, PhD FACMI(and professor of research methods for the last

> 30 years) Sociology Department & School of Medicine & Senior Fellow,





> On 6/21/2015 6:21 PM, robert bell wrote:

> > Good news.

> >

> > Well done Mark and team.

> >

> > Jim, I agree that most errors are ridiculous mistakes and many very

> > simple and not complex. I may be wrong but I think that the serious

> > problems of of the Swiss Cheese phenomena (multiple errors that

> > compound the original problem) could be stopped/helped if the simple

> > things were corrected and less frequent.

> >

> > I would love to see a study, in about 30 - 50 Doctor´s private

> > offices, where there was a 3 month collection run-in period where

> > all the errors that occur are recorded, following interviews with

> > all members of staff (things like no patient call backs for lab and

> > procedures undertaken, switched EKG leads, wrong or delayed

> > diagnoses, forgotten day-before appointment calls, medication

> > refills not called into the pharmacy, etc.). Then randomly give

> > differing instructions to two or three groups of the offices

> > (perhaps different kinds of check lists used at different times) and

> > then seeing what happens to the error rates.

> >

> > Would welcome thoughts on a better structure for such a study to

> > help ensure a better and acceptable outcome.

> >

> > Would litigation issues prevent such a study from ever being

> > undertaken?

> >

> > Once the private offices are "sorted out," then we could better move

> > to medical education and the hospitals!! Or perhaps do them all at

> > once? Would understanding the simple things better would provide a

> > better foundation for other initiatives?

> >

> > Rob Bell, M.D.

Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine

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