robert bell rmsbell200 at YAHOO.COM
Wed Sep 23 19:11:46 UTC 2015

Well said,

Yes, more walking and less talking!

I am wondering about all the other errors (the ? 70%). Diagnostic errors and the other errors are so inter-related that it is difficult to know how you can separate one from the other.

This was my suggestion recently published. PDF and Text below.

This is similar to the Societies plan but embraces the (? 70%). Would welcome comments from list members.

But Mark and the Society have done so well just getting this degree of national attention. They deserve accolades galore.  

Now, hopefully something will happen.

Errors in Medicine:
Do Something Now?
Despite a plethora of data
indicating progress in patient
safety, some experts in the
field think that the situation in
regard to medical misadventure
is not improving. For
example, in January 2015, the
Centers for Disease Control
issued its annual report on
hospital-acquired infections. It
said while dramatic progress
in reducing infections in hospitals
had been made, the
results failed to reach the
national goals set in 2009.
I N S I D E M E D I C A L L I A B I L I T Y 35 T H I R D Q U A R T E R 2 0 1 5
Dr. Peter Pronovost undertook a study at Johns Hopkins that,
in turn, led to a multi-center study in Michigan using his
five-point checklist to ensure proper, sterile insertion of central
venous catheters.1 The study was immensely successful:
1,800 lives and $100 million were saved during the 18
months of the study.
Dr. Pronovost says that the fundamental problem with the quality
of American medicine is that we’ve failed to view the delivery of
healthcare as a science. Further, he says that in order to make this
happen, we will need to understand disease biology,
discover effective therapies, and ensure that
those therapies are delivered effectively.
It would seem that the success achieved by Dr.
Pronovost could well be reproduced in other areas
of medicine, if the desire to do so was similarly
Of course, getting a full understanding of the
complexities of medicine, and all the nuances associated
with preventing errors in medicine, is a
Herculean task that will probably require completely
new approaches to patient interaction, diagnosis,
training, and error-prevention strategies. If this is
to be done properly, it will require greater national
attention, robust funding, and a greater understanding
of all of the elements in healthcare delivery—
all supported by computer programs and systems
far in excess of anything we have now.
However, one could start today by listing what
needs to be done, and then asking interested
groups and organizations to focus on the elements
in the overall problem that they feel they can
undertake right now. In this way, the ball will start
to move—the Pronovost way!
Tasks that need to be
The three lists below are by no means intended to
be complete. But they may give some idea of the
issues that need to be tackled. Further, it would
seem like a good idea to introduce first those things
that seem like common sense and then, if possible,
evaluate and analyze all initiatives, and work
toward ensuring that any change made is
The less difficult tasks
■ Extension of the use of simple lists, similar to
Dr. Pronovost’s ideas, to other areas of medicine
■ Timeouts currently used, e.g., with surgery and, as appropriate, in
other areas of healthcare practice
■ Standards on methods for organizing thoughts
■ Patient visit agendas/passports
■ Providing lists of the most commonly made errors in the various
■ Diagnostic “pearls of wisdom,” and recommendations to help in
distinguishing the more serious diagnostic situations
■ Learning the fundamentals of situational awareness, attention to
detail, and consequential/critical thinking
■ Focusing on prediction, prevention, detection, and correction
■ Improving accuracy and reducing errors in healthcare
professionals’ (HCP) offices that can readily become transferred
to the hospital environment. Most office-based errors may appear
innocuous, but via the so-called Swiss cheese phenomenon,
wherein many small errors become additive, the outcome could
be serious or even fatal.
The more difficult tasks
■ Adoption of team concepts among all HCPs, patients, and local
■ Coordinated communication within and among healthcare
■ Reviewing what is working in the U.S. and the rest of the world to
evaluate what could be introduced generally in the U.S.
■ Finding sound approaches to overcoming language difficulties
■ Hand-washing compliance
■ Medical and allied professional education to embrace safety in
each and every aspect of teaching
■ Obviating pharmacy errors via bar coding and eliminating
confusing abbreviations
■ Introducing proven strategies to minimize laboratory and
radiology errors
■ Addressing electronic health record issues
■ Optimizing the functionality (and privacy) of patient/HCP
■ Adopting community prevention programs
■ Systematic collection and storage of safety data
■ Maximizing what can be learned from the airline and other
■ Recommend that every HCP private office has the equivalent of
a safety officer, who collects data on error incidents and regularly
conveys that to the HCP and other office staff on a periodic basis
for handling/correcting.
The very difficult tasks
■ An accurate nationwide data-collecting system for errors in
■ Simulator training
■ Countering the widespread problem of owing some measure of
allegiance to a code of silence, commonly coupled with a strong
desire to resist change
■ Correlating root cause analyses and failure modes effects analyses
results with patient safety initiatives, and assessing the resulting
reduction in errors
■ Overcoming a lack of transparency
■ Finding strategies to tackle the relative sense of the unimportance
of prevention in medicine
■ An appreciation that in complex systems, changes to one part of a
system can significantly affect other parts
■ Finding solutions to the current challenges to telemedicine
■ Securing the requisite data to obtain an accurate overview of the
national situation
■ Harnessing advanced computers to help in case management and
in reducing diagnostic errors
■ Securing sufficient funding to make all of this happen.
While there are multiple organizations participating in preventing
errors in medicine, what seems to be missing is a collective and coordinated,
nationwide approach to the various elements of the problem.
The concept of a consortium of interested parties that would drive the
process would be well worthwhile investigating. Such a consortium
with a commitment to making tangible progress on patient safety,
could coordinate and advise on the specific studies to be undertaken.
Further, safety measures that are working well could be communicated
by the consortium to as many HCPs as possible.
We can ask, “Do we have to wait for ‘Singularity,’ the point when
advanced computers are expected to be more intelligent than the
human mind, to drive the process forward?” Estimates indicate that
that might take 30 years or even longer.
Ranking the relative difficulty of the challenges we face, and then
holding conferences to address the tasks for each level of challenges,
would serve to divide up the massive task of ensuring patient safety
into something that is far more manageable. A dedicated conference,
for the less difficult tasks, could be held fairly quickly, and then that
could become a bottom-up endeavor, passing from one group of HCPs
to another. This is important, since there does not seem to be the political
will in the U.S. to make this a top-down initiative.
Such a dedicated conference should have a well-defined purpose
and goal, with a focus on patients. Interested patient safety organizations
and specialty societies, as well as the insurance and hospital
industries and other stakeholders could take on the aspects of the
challenge that they, within their budgetary restraints, feel comfortable
in handling. It might just be one or two small tasks or studies that an
organization would be comfortable undertaking—but every small
initiative would be contributing to the whole.
It would be best if each participating group could organize and
fund its own projects, with any studies undertaken being done with
the cooperation of hospitals and academic institutions, when and
where necessary. General funding would help move the process forward,
but this is not absolutely necessary to get things started and
Consider: If we can put a man on the moon and are now planning
to send humans to Mars, surely we can do something on a national
scale that could improve patient safety.
The Institute of Medicine is, in 2015, to issue a report on errors in
diagnosis (estimated now to be about one-third of all errors in medicine).
The 64th Annual Scientific Session of the American College of
Cardiology was held in Southern California in March 2015. The meeting,
it was said, was designed to be innovative, interactive, and informative,
and would leverage the entrepreneurial environment of Southern
California to inspire registrants. What an invitation to attend!
So much could be done toward the goal of preventing errors in
medicine with the right leadership, inspiration, and the willing
cooperation of many.
1. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease
catheter-related bloodstream infections in the ICU. N Engl J Med
I N S I D E M E D I C A L L I A B I L I T Y 36 T H I R D Q U A R T E R 2 0 1 5
> On Sep 23, 2015, at 11:37 AM, Bob Latino <blatino at reliability.com> wrote:
> FYI - I am glad Bob Wears chimed in with a reality check.  Time to 'walk the talk' and demonstrate results rather than talk endlessly about the problem.
> Robert J. Latino, CEO
> Reliability Center, Inc.
> 1.800.457.0645
> blatino at reliability.com
> www.reliability.com
> -----Original Message-----
> From: Robert L Wears, MD, MS, PhD [mailto:wears at UFL.EDU] 
> Sent: Wednesday, September 23, 2015 12:31 PM
> Subject: [IMPROVEDX] disappointed
> Great that misdiagnosis and related failures are getting attention, but ...
> This is a disappointing effort; a naïve, keyhole view of a complex problem.
> I count 82 mentions of 'error' in the first 15 pages (~5.5 per page), 753 in the entire document.
> Lots of discussion about biases (78 mentions) but important issues that challenge the focus on 'error', such as hindsight bias, or outcome bias, are never mentioned even once.
> This restriction to a very narrow framing of the problem is unlikely to lead to progress.
> bob
> 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
> Nothing matters very much, and very few things matter at all.
>                                                  ---Balfour
> Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine
> To unsubscribe from the IMPROVEDX list, click the following link:<br> <a href="http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1" target="_blank">http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1</a>
> </p>

Robert M. Bell, M.D., Ph.C.
P.O. Box 3668
West Sedona, AZ  86340-3668
Tel: Fax: 928 203-4517

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

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