Doctors Company Foundation Grant - Great News

Robert L Wears, MD, MS, PhD wears at UFL.EDU
Thu Jun 25 16:16:34 UTC 2015


very nice, I'll have to read it.

Erik Hollnagel said much the same thing in a conf on human error trigged by Three Mile 
Island in 1990.  See:

HollnagelE. Does human error exist? In: Senders JW, Moray NP, eds. Human Error:  Cause, Prediction, 
    and Reduction. Hillsdale, NJ: Lawrence Erlbaum Associates; 1991: pp 153.

On 23 Jun 2015 at 14:05, Bruno, Michael wrote:


> 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 Amazon.com for as little as $ 0.04
> - well worth the investment!
> 
> 
> 
> Mike
> 
> 
> 
> http://www.amazon.com/Being-Wrong-Adventures-Margin-Error/dp/006117605
> 2
> 
> 
> 
> 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
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> 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.
> 
> 
> 
> bob
> 
> 
> 
> 
> 
> 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,
> 
> > LDI Wharton School UNIVERSITY OF PENNSYLVANIA
> 
> >
> 
> >
> 
> >
> 
> > 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.
> 


Robert L Wears, MD, MS, PhD
University of Florida  	Imperial College London
wears at ufl.edu       	r.wears at imperial.ac.uk
1-904-244-4405 (ass't) 	+44 (0)791 015 2219
Even in the valley of the shadow of death,
two and two do not make six.
                              --L Tolstoy






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