Bob Latino blatino at RELIABILITY.COM
Tue Dec 8 19:35:19 UTC 2015

I have a question:

How many believe that current regulatory and procedural compliance equates to actual improved patient safety?

It would seem that in light of increased regulations in this area of patient safety since the 1999 IOM report, that medical errors have been on the increase.

Meanwhile the overwhelming majority of the approximate 6,000 U.S. hospitals, are accredited by the various deeming authorities.  Is there a disconnect?

I think Amy's post below addresses this point.  How come when we follow all the 'rules', the patient seems to still lose out in the end?

This is typically what happens in industries that operate in silos, and do not operate as integrated, effective systems.

Thanks Rob for promoting a 'questioning attitude' and trying to make a difference in the short term.

I am not a clinician but am a medical error investigator. In my experience, one thing we can do right now to make a huge difference, is look in a mirror when failures occur and ask ourselves if we could be a part of the problem?  Absent this, we look at everyone else as the problem, therefore they have to fix it.

That would be a huge step forward to uncovering the truth and making quick, quantifiable progress in improving patient safety!

Robert J. Latino, CEO
Reliability Center, Inc.
blatino at

From: Amy Reinert [mailto:amy.reinert at GMAIL.COM]
Sent: Tuesday, December 08, 2015 8:20 AM
Subject: Re: [IMPROVEDX] Questions

You raise some interesting questions here, Rob.

In response to your question about one thing that could be done right now that could save lives or reduce injuries caused by errors in medicine, I suggest that taking responsibility for individual patients under the doctor's care seems to be something that has fallen by the wayside as medical care delivery becomes increasingly systems oriented and commercialized.

I see several clients in my practice who have serious chronic illnesses and are in various stages of diagnosis and treatment. One theme that I have picked up from them is that there is a great deal of frustration that they get handed off to one specialist or another, then referred back to primary care, and out to specialists again, but with all this bouncing around, nobody really takes charge of the case and commits to finding the correct diagnosis and appropriate treatment. This seems particularly true for patients with autoimmune diseases. I am not suggesting that each physician isn't doing their best, but rather, that the patients are suffering because the PCP refers the patient out as necessary, but the specialists keep a narrow focus only on their area of interest. Care then becomes piecemeal, lots of communication errors and failures occur between medical offices, necessary tests are not conducted, or tests are unnecessarily repeated. One of my clients used the analogy that his care was like paying good money for concert tickets to hear a beautiful piece of music, but the conductor wasn't there, so the music is reduced to cacophony. Another client arrived at her session one day in tears, because an accurate diagnosis had been made for her two years previously, but there was a communication error and so she never got the call from the doctor or the nurse, never received prescription information, and therefore continued her diagnostic quest for another 24 months. She learned this through a strange set of circumstances that people of faith might describe as Divine intervention. She spent a lot of time grieving two years of her life where she might have been feeling better and more able to participate in her own life. Interestingly, in that two year quest, nobody else picked up the correct diagnosis.

My guess would be that each doctor perhaps does feel that they are being responsible for the patient without realizing what is being left unaddressed because nobody is keeping an eye on the big picture of the patient's condition. I remember that PCP's used to do this. Perhaps they are still supposed to?

Systems and procedure policies are intended to reduce human error and increase efficiency. Unfortunately, they also tend to provide a practical shield from individual responsibility (I say practical because it might seem safe to practice medicine behind the systems and policies, but the doctor can still get sued). When service to the systems and policies becomes greater than service to the patient, an element of humanity is removed from the process. It seems to me that a great many of the problems in diagnostic accuracy result from this. I don't think anyone does this intentionally. It is the nature of the beast.

All the best,
Amy Ruzicka, Ph.D.

On Saturday, December 5, 2015, robert bell <0000000296e45ec4-dmarc-request at<mailto:0000000296e45ec4-dmarc-request at>> wrote:

Do those working in the Medical industry ask enough questions?

Would asking more  questions lead to creativity, and that then lead to solutions, and finally to saving more lives and injury from errors in medicine?

Are we making enough progress with Errors in Medicine?

What is the one thing, that we could do right now, that would save some lives or reduce injuries caused by errors in medicine?

Robert Bell, M.D. Ph.C.



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