Another look at Questions

Michael.H.Kanter at KP.ORG Michael.H.Kanter at KP.ORG
Thu Jan 7 16:53:37 UTC 2016


In terms of a list of Do's and Dont's this could help.  I think the 
challenge will be to find Do's and Dont's that are simple enough to 
describe but at the same time can meaningfully reduce errors.    It is 
worth exploring though. 

Michael Kanter, M.D., CPPS
Regional Medical Director of Quality & Clinical Analysis
Southern California Permanente Medical Group
(626) 405-5722 (tie line 8+335)
THRIVE By Getting Regular Exercise

NOTICE TO RECIPIENT:  If you are not the intended recipient of this 
e-mail, you are prohibited from sharing, copying, or otherwise using or 
disclosing its contents.  If you have received this e-mail in error, 
please notify the sender immediately by reply e-mail and permanently 
delete this e-mail and any attachments without reading, forwarding or 
saving them.  Thank you.




From:   robert bell 
<0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>
To:     IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Date:   01/07/2016 07:21 AM
Subject:        Re: [IMPROVEDX] Another look at Questions



Dear Michael,

Some good points. 

One of my thoughts is that we have the cart before the horse in first 
focussing on Errors in Diagnosis when something like 60% of errors are run 
of the mill standard errors. These such as communication problems that are 
associated with simple things like orders, wrong medications, computer 
problems, fatigue, education lack, and language problems. If we are truly 
interested in reducing the death toll and morbidity of Errors in Medicine 
as a whole should we not go for the jugular, identify the biggest 
problems, and tackle these collaboratively so that we get a significant 
reduction in the figures. 

And that brings up a big issue that first we need to have figures to be 
able to say if we are making progress. And think of the revolution that 
will create when we get into litigation and confidentiality discussions. 
That big question seems to be, can we do anything meaningful in either 
Standard and Diagnostic Errors without good data?

I take your point that a large percentage of lab and x-ray reporting is 
related to diagnosis, but it is also related to monitoring over time - 
INRs, mammograms, and bone density come to mind. I do not know the 
monitoring percentage but would guess it is 10 - 20% of the total.  As 
these two specialty areas are so important to the whole of medicine it 
would seem that the consortium of specialty societies (that incidentally 
should have patient representation) could triage the main problems in 
these areas and collaboratively work on improving them. From what I hear 
the electronic patient record would be something that should be looked at 
immediately. If you do not look after the important basic foundations of 
medicine and the standard 60% of all errors that accounts for the biggest 
mortality I believe that you are never going to effectively make inroads 
into the Diagnostic Error piece of the pie.

I am sure that with the benefits of technology there are many 
opportunities to reduce/improve the number of errors in both Radiology and 
Laboratory pathology.  And yes, you are correct radiology is likely to 
help make accurate diagnoses sooner than an impression made with a 
stethoscope (incidentally I have often wondered how accurate, in certain 
hands, the stethoscope is and have questioned what is its contribution to 
errors - perhaps it should be triaged close to the top!). But the 
technological advances in radiology would place it in the forefront for 
improvement of error rates.

So this does not mean that we should not be focussing on Diagnostic Errors 
as we move forward, but strongly believe we should first be making sure 
that the main foundations to diagnosis are as solid as they can be.

Yes, specialists with telemedicine links to help in the review process 
would be a wonderful idea to help with error rates.  And also a wonderful 
teaching tool to both specialist and radiologist. Could well be tried out 
with a small study if it is not already being done.

One of my thoughts is that in medicine that is structured hierarchically 
we may not be asking enough questions. Particularly as technology and 
collaboration is slowly eroding that hierarchy. Questions are often less 
intrusive and more than anything are creative in group settings. Questions 
should be encouraged in all meetings if we wish to make quick progress.

Do you think that Do and Don’t lists are of value?

Thank you Michael,

Rob Bell


On Jan 6, 2016, at 4:54 PM, Michael.H.Kanter at KP.ORG wrote:

interesting thoughts that you wrote below that are very thought provoking 
as usual.  Maybe I misunderstood but  you make the statement that " I felt 
that if there is a significant error rate in radiology reports and 
laboratory tests that this should be addressed first." 
I personally consider error rates in radiology reports and lab tests 
within the scope of diagnostic errors and not sure why we would not 
address this quickly.   I do not believe that anywhere in the IOM report 
did they suggest otherwise.    In fact, radiology report errors really 
fall into the class of diagnostic errors related to visual errors and also 
occur in pathology reports and other areas of diagnosis where the 
diagnosis is made by visual interpretation of an image.  We recently 
published a method on how to decrease these for interpretation of retinal 
photos   
Visual errors that are based on stored images (as opposed to looking at a 
skin lesion of a patient) have some advantages in terms of study and 
performance improvement including 
1) they are often stored in data systems for easy retrieval and 
identification 
2)  they can be retrospectively reviewed 
3)  one can determine the incidence of diagnosing a disease if the image 
or image results are stored in a data system and use the variation in 
diagnosis as a measure of diagnostic error/variability as was done in the 
attached paper. 
4)  Diagnosis based on visual images can be more easily studied because 
the variable of data acquisition can be controlled better (that is 
everyone can look at the same image/data) which is very different than a 
physical exam or patient history. 

My point is that it may be simpler to study errors due to visual 
interpretation of images than other types of diagnostic errors and this is 
something to consider addressing sooner rather than later. 

I really like the idea of specialists societies getting involved in 
diagnostic errors.    Specialists  are likely to see such errors in their 
practice when referals are sent too late or with the wrong diagnosis. 

Michael Kanter, M.D., CPPS
Regional Medical Director of Quality & Clinical Analysis
Southern California Permanente Medical Group
(626) 405-5722 (tie line 8+335)
THRIVE By Getting Regular Exercise

NOTICE TO RECIPIENT:  If you are not the intended recipient of this 
e-mail, you are prohibited from sharing, copying, or otherwise using or 
disclosing its contents.  If you have received this e-mail in error, 
please notify the sender immediately by reply e-mail and permanently 
delete this e-mail and any attachments without reading, forwarding or 
saving them.  Thank you.




From:        robert bell <
0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG> 
To:        IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG 
Date:        01/02/2016 04:03 PM 
Subject:        [IMPROVEDX] Another look at Questions 



Dear All, 

I would like to thank all the people on this list who kindly responded to 
my questions a few weeks back. 

Since asking those questions I became aware that questions may be 
creative. 

Does it follow then that statements are less creative. I then thought how 
does that come about? 

A question I thought, stimulates listeners and readers to think of various 
solutions. So from one question you might get many solutions. With 
statements you would be more relying on the creativity of the writer 
presenting his or her various ideas and solutions. And these all together 
may not be great in number. 

With regard to the medical profession as a whole and people in positions 
of power in the healthcare industry who can effect change, one can ask do 
they ask fewer questions for fear of being considered less knowledgeable? 
So, if this is true, almost by definition, if questions are creative, such 
decision makers are less likely to be broadly creative, at least 
initially? There are obvious exceptions. So a  question might be how to 
better take advantage of the crowd think? 

This all makes an assumption that most things in medicine are complex and 
that many solutions to an issue may be necessary to arrive at a good 
solution. 

The IOM has issued its statement/report on diagnostic errors and there are 
some good suggestions. I was pleased to see teamwork mentioned first in 
their solution. Which essentially is an extension of crowd think. 

But the big question is where do we go from here? As you all know I would 
have preferred standard medical errors to be approached first before 
diagnostic errors. For example, I felt that if there is a significant 
error rate in radiology reports and laboratory tests that this should be 
addressed first. But assuming that we may have the cart before the horse, 
and I am not completely sure about that, what questions could be asked of 
the established consortium of speciality societies? 

Over and above the big structural solutions, what comes to mind for me is 
that some of these societies have issued Do and Don’t lists for their 
members. 

So my new question is, could those lists be looked at and the idea 
extended to all the specialty societies with the emphasis on reducing 
diagnostic error? 

Also, with any statement(s) would it be good to consider asking some 
questions at the end to stimulate thought? 

The best for 2016, 

Robert M. Bell, M.D., Ph.C. 






Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG

To unsubscribe from IMPROVEDX: click the following link:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1 

or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG

Visit the searchable archives or adjust your subscription at: 
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX 

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

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

<OSLIRetinaPDF.pdf>

Robert M. Bell, M.D., Ph.C.
P.O. Box 3668
West Sedona, AZ  86340-3668
USA






Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG

To unsubscribe from IMPROVEDX: click the following link:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1 

or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG

Visit the searchable archives or adjust your subscription at: 
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX

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

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



To unsubscribe from the IMPROVEDX:
mail to:IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
or click the following link: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG

Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG

For additional information and subscription commands, visit:
http://www.lsoft.com/resources/faq.asp#4A

http://LIST.IMPROVEDIAGNOSIS.ORG/ (with your password)

Visit the searchable archives or adjust your subscription at:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX

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>

HTML Version:
URL: <../attachments/20160107/17a58e23/attachment.html>


More information about the Test mailing list