Do Something Now!

Bob Latino blatino at RELIABILITY.COM
Fri Oct 2 19:32:02 UTC 2015


Rob

As an expert in RCA for the past 30 years (not a clinician, but a methodologist), I do not see why the true, proven principles of effective RCA would not be applicable to any undesirable outcome, no matter what umbrella/category it was under.  The deductive reasoning process used to understand how the bad outcome came to be, would be the same.  The use of evidence to validate hypotheses would be the same, no matter what the bad outcome being analyzed, would be. The drive to understand human reasoning would be the same.


[cid:image002.jpg at 01D0FD28.0DD8DE20]
In the above Fishbone Diagram (from slide 40 of the link you provided), an analyst could drill down much deeper on each of the conclusions to uncover much more 'meatier' latent root causes.  But I believe the analysis stopped short of the 'meat'.  Many of the research cause categories were injected or often referred to as the 'fish bones' (which the average analyst would have little to no subject matter knowledge of); but just because the categories were made available, does not mean there is automatic depth to the RCA.

Technically, I am not a fan of the Fishbone Diagram because of such technical constraints (the ability to drill down deeper into human reasoning and using hard evidence to guide the drilling process)

To me, the true objective of an effective RCA, is an intimate understanding of why a well-intentioned decision-maker made a poor decision (what I refer to as a human root or a decision error).  When we explore 'why' someone felt the decision they made at the time was the correct one, then we will start to uncover the systemic nature of the failure (what I refer to as latent root causes or management system flaws).  This would be the reasoning side of any decision that resulted in a bad outcome.
For instance, I will take a few of the fish bones from above and drill a little bit deeper) to make my point:
1. "Hyperkalemia and hypertension ignored despite persistence"  - This is not the end, it is the beginning...
Why did we ignore Hyperkalemia and hypertension despite persistence? Is this a common practice that evolved (normalization of deviance) in this organization?
2. "Multiple Handoffs"
Why were there multiple handoffs? Were there more than there should have been? Were the handoffs mis-handled (if so, How?)?
3.  "Patient Cannot Navigate System"
Why Not? What is deficient about the design of the system that makes it so difficult for the patient to navigate the system? Wasn't the system tested using patients that would use it, in the design phase? if not, Why not?
4. "Fatigue Discounted"
Why was Fatigue Discounted? Was is not recognized? Was it recognized and discounted? What was the reasoning for discounting it? Lack of knowledge/education of the person making the judgement call?
I believe there is much more productive 'meat' in the fish bones expressed above, by drilling down and uncovering more specifics.  I could not see myself being able to write an effective recommendation on these conclusions  because they lack such specificity. How do you write a recommendation for 'Fatigue Discounted' when you don't know why it was discounted?  The conclusion is too generic to me.  This is like drawing a conclusion of 'Poor Communication'.  How do I write an effective recommendation/corrective action for that?
Why people make the decisions they do is way more important than who made the decision (unless there is malice with intent which is typically very rare).
I have spent a career trying to defeat the paradigm of

"We never seem to have the time and budget to do things right, but we ALWAYS seem to have the time and effort to do them again".

Is diagnosis error any different?

Bob


Robert J. Latino, CEO
Reliability Center, Inc.
1.800.457.0645
blatino at reliability.com
www.reliability.com

Robert J. Latino, CEO
Reliability Center, Inc.
1.800.457.0645
blatino at reliability.com
www.reliability.com

From: robert bell [mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG]
Sent: Thursday, October 01, 2015 4:33 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Do Something Now!

Thank you - I somehow thought that studying diagnostic and therapeutic errors together would be beneficial.

And I understand the similarities that you draw from the diagnostic and treatment process.

I was thinking of research in Root Cause Analysis (RCA) where it would seem valuable to study both diagnostic and other errors to draw out the the similarities or lack of. I think I am correct in saying that RCA is not commonly undertaken with Diagnostic Errors. I found this article on the web in which Mark Graber and colleagues had outlined the way in which a Diagnostic RCA evaluation might be done. https://c.ymcdn.com/sites/www.npsf.org/resource/collection/A81D4178-F1E9-4F87-8A85-CA89DEBB953F/How_to_Do_a_Root_Cause_Analysis_of_Diagnostic_Error_Handout_Slides.pdf this would seem to be an opportunity to build the RCA diagnostic error literature and make appropriate comparisons between the two groups of errors to learn far more.

"It is only with attempts to capture all the rules that would enable automatic detailed computer protocols that we leap beyond the limitations of ordinary clinician thinking in medicine.” I agree and in the development of computer protocols it would seem valuable to be studying diagnostic and therapeutic errors side by side. Computers are essential for significant advance in the diagnostic process and it would seem that understanding just how therapeutic errors occur and not how the more frequent other errors occurred would be counter productive.

I made suggestions below on how this could happen. Those ideas are in no way cast in concrete and are just a suggestion for discussion so that we move forward and do something now.

Rob Bell, MD


On Sep 28, 2015, at 5:47 AM, Alan Morris <Alan.Morris at IMAIL.ORG<mailto:Alan.Morris at IMAIL.ORG>> wrote:

Thank you all.

This is an interesting conversation with many important insights.  I believe Dr. Bell is correct that error, both diagnostic and therapeutic, would be best studied together.  My underlying reason for this conclusion is the common source of both kinds of error: the clinical decision-maker.  Clinicians are prone to error, like all humans, because of multiple issues that include being overburdened with tasks, human cognitive limitations, and information overload.  These are common to diagnostic and therapeutic error.  Focusing on the clinician decision-maker and enabling consistent (replicable) decisions, for a given input data set should be the target for both diagnosis and treatment.  Detailed, context sensitive, computer protocols that generate patient-specific (personalized) instructions are, I believe, the only consistent means of achieving this goal.

The recent important Institute of Medicine publication focuses needed attention on diagnostic error, but addresses the use of decision-support rather superficially.  The authors appear to lump decision-support, as if a monolithic enterprise, into one category.  “Protocol” appears three times but only in reference to imaging studies.  “Decision support” appears more frequently, but in a superficial context.  They use a definition from HealthIT.gov<http://healthit.gov/> “clinical decision support (CDS) tools. CDS provides clinicians and patients “with knowledge and person-specific information [that is] intelligently filtered or presented at appropriate times, to enhance health and health care”.  Nowhere do they mention replicable or reproducible methods or automatic (closed-loop) protocols.  This publication likely reflects systematic health care barriers to disruptive technologies – technologies that are needed to support clinician decision-makers, if we are to make desired progress with  our health care problems.

A major benefit emerges when one attempts to identify the detailed rules and input data required to make decisions for specific medical tasks.  This is the most educational process my colleagues and I have engaged.  It is only with attempts to capture all the rules that would enable automatic detailed computer protocols that we leap beyond the limitations of ordinary clinician thinking in medicine. D This is an iterative process (in 3 decades of such work, my colleagues and I have never initially anticipated all the issues that required attention).  Dr. Papier and others have indicated that the diagnostic process is also iterative.  Interestingly, there are only few comments about the importance of using electronic systems to assure complete input data during the diagnostic process – a requirement Dr. Larry Weed has emphasized for decades.  Dr. Kodolitsch and others have indicated the importance of addressing analog and digital information.  One must, even if using fuzzy logic, eventually defuzzify the result and digitize the output so clinicians know whether or not to act in a specific way.

I think this group should seriously consider Dr. Bell’s important suggestion.

Alan H. Morris, M.D.
Professor of Medicine
Adjunct Prof. of Medical Informatics
University of Utah

Pulmonary/Critical Care Division
Sorenson Heart & Lung Center - 6th Floor
Intermountain Medical Center
5121 South Cottonwood Street
Murray, Utah  84157-7000, USA

Office Phone: 801-507-4603<tel:801-507-4603>
Mobile Phone: 801-718-1283<tel:801-718-1283>


From: robert bell <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG<mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, robert bell <rmsbell200 at YAHOO.COM<mailto:rmsbell200 at YAHOO.COM>>
Date: Saturday, September 26, 2015 at 16:42
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Subject: [IMPROVEDX] Do Something Now!

Dear all,

I am very pleased that I have been asked to post to the list an article that I wrote back in March that has just been published in Inside Medical Liability (I have no association or connection with PIAA other than being approached by their editor to write and publish an article).

The article provides a suggestion as to how the US could move forward for BOTH Diagnostic and All Other Medical Errors. The plan suggests preliminary meetings to triage the issues and to develop a consortium of specialty and medical safety societies that would take on the tasks they could handle and afford.

This idea is similar to what SIDM has been doing but involves All errors, not just Diagnostic. I am not sure what the % breakdown of diagnostic and other errors is, but it has in the past been said to be 30/70% (I am not sure how to convert the IOM figures of 5% of outpatients, 6 - 17% of hospital patients, and approximately 4 - 5 million each year [the IOM 1 per lifetime].

To me it seems sad that with the Diagnostic Error IOM report that 70%, or maybe more, of the pie is not being handled. And within that portion of the pie there may be many more easier approaches that could be “quickly" introduced to do something Now. This compared to some of the complexities in the Diagnostic pie portion that may be a lot more difficult. And if the diagnostic errors are less than the 30% often mentioned, then it seems even more necessary to focus on All the Other Medical Errors as well.

Further, as Diagnostic and All Other Errors are so interrelated a case can be made that all should be tackled as a whole. Can Errors in medicine effectively be dissected out from All Other Errors?

Also, what is the mortality and degree of injury in Diagnostic Errors as opposed to All The Other Errors? Should one be triaged and dealt with first, or should they both be handled together if we are to start Doing Something Now and saving lives? With the All Other Errors being a larger portion of the pie would tackling that first or with diagnostic errors be a viable option.

I am not precisely sure what the solution is to achieve a way forward, but I wondered if SIDM could expand the Coalition to handle the All Other Errors with SIDM leading the way. Paul Epner has told us that there is an intent to grow the Coalition. A big task, but with good leadership, help from many, and cooperation it could be done.

Could the IOM now be asked to do a quick report on All The Other Errors? Perhaps even one of the other societies could lead the way with All Other Errors! So many options.

I am so encouraged with what SIDM has done, that their foot is in the door, and there would seem to be an opportunity for them to guide or lead the way with all errors.

Would welcome full and open discussion.

This is the article, with text below.


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Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine

To learn more about SIDM visit:
http://www.improvediagnosis.org/


Kindly,

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


I N S I D E M E D I C A L L I A B I L I T Y 34 T H I R D Q U A R T E R 2 0 1 5
Robert M Bell, MD, is now retired. He has
worked in retail pharmacy, academic
pharmacology, pharmaceutical medicine, and family
medicine, with an interest in errors in medicine;
Rmsbell200 at yahoo.com<mailto:Rmsbell200 at yahoo.com>.
Errors in Medicine:
Do Something Now?
 R OBERT  M. BELL , MD
F E A T U R E S T O R Y
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
motivated.
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
addressed
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
evidence-based.
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
sub-specialties
■ 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
communities.
■ Coordinated communication within and among healthcare
facilities
■ 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
portals
■ Adopting community prevention programs
■ Systematic collection and storage of safety data
■ Maximizing what can be learned from the airline and other
industries
■ 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
medicine
■ 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
underway.
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.
Reference
1. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease
catheter-related bloodstream infections in the ICU. N Engl J Med
355(26):2725-32.
D O S O M E T H I N G
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
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?

________________________________

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Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine

To learn more about SIDM visit:
http://www.improvediagnosis.org/

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




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