Another great example of failure to diagnose

Regan, Elizabeth ReganE at NJHEALTH.ORG
Sat Feb 13 14:59:59 UTC 2016


I just listened to the podcast for This American Life that is linked to a companion NY Times article. (Link from the NYTimes website). It tells the story of a young man with bipolar illness who sought care in a Houston hospital when he had an acute manic episode.  He told the ER staff he was manic. They didn't listen. Later, his father who was a physician asked for a psych consult. The nurse didn't listen or take action. He was then shot in the chest by Houston police officers moonlighting as security when he became agitated.

Listen to the story. It makes me want to weep for a profession that is allowing administrators to make decisions about how a mentally ill patient is managed when he decompensates.  I also want to rage at nurses and doctors who can't see the faces of suffering and illness and would mindlessly turn a patient over to security guards instead of calming and caring for him.  I am really tired of hearing people say, "I told them, but they didn't listen".  I've heard it myself and it is part of an arrogance in the profession that denigrates those we serve.

There were many great nurses and doctors there who clearly did right - recognized his need, saved him from the GSW, but for those who didn't....
I don't want them to go forward as caregivers in our profession.
The CEO  of St Joseph hospital in Houston says they would do it again.  He needs to lose his job and leave healthcare. He doesn't understand what the job is.

Liz Regan
Sent from my iPad

On Feb 13, 2016, at 4:25 AM, DR WILLIAM CORCORAN <williamcorcoran at SBCGLOBAL.NET<mailto:williamcorcoran at SBCGLOBAL.NET>> wrote:


·      Involvement of Authority

An inescapable fact is that conditions, behaviors, actions, and inactions were what they were[2]<https://us-mg5.mail.yahoo.com/neo/launch?.partner=sbc&.rand=09r61vkpotg98#_ftn2> because those in authority wanted them that way, tolerated their being that way, or didn’t know that they were that way. This applies from the work location to the top governance.

________________________________

[2]<https://us-mg5.mail.yahoo.com/neo/launch?.partner=sbc&.rand=09r61vkpotg98#_ftnref2> Posted at the interesting article at http://lifelinestrategies.com/2016/01/31/supervisors-gone-rogue/#comment-145

Take care,

Bill Corcoran


William  R. Corcoran, Ph.D., P.E.
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
William.R.Corcoran at 1959.USNA.com<mailto:William.R.Corcoran at 1959.USNA.com>
http://www.linkedin.com/in/williamcorcoranphdpe
https://www.box.com/shared/kfxg1lt9dh



On Friday, February 12, 2016 12:57 PM, Peggy Zuckerman <peggyzuckerman at GMAIL.COM<mailto:peggyzuckerman at GMAIL.COM>> wrote:


I spoke to a head nurse in a Seattle hospital who was so frustrated about her team being on the hunt for necessary materials, from linens to band-aid, that she tracked the number of lost hours per shift.  Only when the administration was shown that over 3 hours per 8 hour shift were lost in the searches, did they institute a series of changes which had those supplies refilled automatically in multiple locations by non-nurses.

The administration was clearly concerned, but had no idea of the magnitude of the problem.  But providing the metrics in terms of the loss of time/money made the difference.  Certainly the same approach will be effective when those observations can be linked with the analysis of costs to the institutions and patients.

Peggy

Peggy Zuckerman
www.peggyRCC.com<http://www.peggyrcc.com/>

On Fri, Feb 12, 2016 at 3:05 AM, DR WILLIAM CORCORAN <williamcorcoran at sbcglobal.net<mailto:williamcorcoran at sbcglobal.net>> wrote:
One of my mentors loved to repeat:

A short pencil is better than a long memory.

Take care,

Bill Corcoran


William  R. Corcoran, Ph.D., P.E.
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
William.R.Corcoran at 1959.USNA.com<mailto:William.R.Corcoran at 1959.USNA.com>
http://www.linkedin.com/in/williamcorcoranphdpe
https://www.box.com/shared/kfxg1lt9dh



On Thursday, February 11, 2016 10:27 PM, Bob Latino <blatino at RELIABILITY.COM<mailto:blatino at RELIABILITY.COM>> wrote:


Hi Peter

I thought you might like this concept.

Care Journals by The Josie King Foundation

http://www.josieking.org/carejournals

I have always liked this idea of providing patients Care Journals to keep records during loved one's stay in a hospital.  I think all involved 'win' when everyone actively participates in the quality delivery of care.

Just an FYI.


Robert J. Latino, CEO
Reliability Center, Inc.
1.800.457.0645
blatino at reliability.com<mailto:blatino at reliability.com>
www.reliability.com<http://www.reliability.com/>

From: Elias Peter [mailto:pheski69 at GMAIL.COM<mailto:pheski69 at GMAIL.COM>]
Sent: Wednesday, February 10, 2016 4:45 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Researchers want a better system for fixing bad science | The Verge

" I kept daily lists of the errors and worked with the Risk Managers to resolve.”

If I had a magic wand, I would require that all hospitals create a group of 'safety observers’ that would include patients, provide some training in systems and medical care, and then pay them to sit and observe and take notes and report regularly (monthly at least) to administration/risk management and involved departments to identify, prioritize, and address safety issues.

I think there is a simple logic to this: direct observation of process by independent individuals with different perspectives will see and find things that no fancy internal risk management system will see.

Peter Elias, MD

On 2016.02.09, at 7:50 AM, Bob Latino <blatino at RELIABILITY.COM<mailto:blatino at RELIABILITY.COM>> wrote:

The U.S. spends ~17% of its GDP on Healthcare or about $3 Trillion/yr (or ($9,323/person).  It is hard to believe we do not throw enough money at it.  It is how we use the monies so inefficiently and ineffectively that is the problem.  For all of the money thrown at HC, our mortality rates as compared to the rest of the world do not demonstrate ours was money well spent.  Why not?

To put this into perspective France and Switzerland spend 11% of their GDP on healthcare.  The Middle East spends much less (see below).

<image003.png>

Source: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/highlights.pdf
Source: https://www.cia.gov/library/publications/the-world-factbook/rankorder/2066rank.html
Definition: The crude death rate is the number of deaths occurring among the population of a given geographical area during a given year, per 1,000 mid-year total population of the given geographical area during the same year.

Because the manner in which death rates are collected, deaths due to 'medical' error are not uniformly collected or collected at all in many countries.  So the only uniform measure of death is called the 'crude death rate' around the world (see definition above).  Deaths due solely to medical error are included however, the split (%) is not discernible.  Regardless, when you look at the investment in HC as opposed to GDP, and overall crude death rate/1000 total population, the numbers are varied and quite startling.  Why do these countries with the lowest investment in HC as a % of their GDP, also have the lowest crude death rates in the world?

I know there are many researchers on this forum who will chew this up and explain to us the reasons; but as a layman, I am interested in learning why.

Irrespective of what the studies in the link Rob provided conclude, just sitting in any hospital for a day and observing, one can make a list of errors for themselves.  To me, it is hard to imagine a hospital stay without an error occurring the course of the delivery of care.  Both of my parents passed in the last 9 years and both were in ICU's for 2 - 4 weeks.  We stayed with them 24/7 during those stays.  I kept daily lists of the errors and worked with the Risk Managers to resolve.  I know what I am looking for, just think of those who do not and just 'trust' their care givers and their delivery of care systems. Are they told of these errors?

I believe Rob's point is not that the errors are not occurring, but what is the scope and magnitude of them?  How do we accurately identify, quantify and prioritize them so we can focus on solving them in a logical manner?  How do we do this in a fashion where actions replace words and change can be observable in the near term (instead of during our lifetime)?  Certainly there are more complex issues that will take longer to resolve but I believe the 80/20 applies here as well.  I suspect that 20% or less of the error types (Failure Modes we call them in my business) account for 80% or more of the total occurrences.  Certainly we can act on this 'low hanging fruit' in the 20% range (or what we call the Significant Few).

Bob Latino


Robert J. Latino, CEO
Reliability Center, Inc.
1.800.457.0645
blatino at reliability.com<mailto:blatino at reliability.com>
www.reliability.com<http://www.reliability.com/>


-----Original Message-----
From: Robert Bell [mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG]
Sent: Monday, February 08, 2016 10:09 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: [IMPROVEDX] Researchers want a better system for fixing bad science | The Verge

http://www.theverge.com/2016/2/3/10897938/science-correction-process-problems-report-university-alabama

This supoports the concept that the diagnostic infrastructure is overall in a bad state. Is money the big problem - too much or too little?

Rob Bell
Sent from my iPad
To unsubscribe from the IMPROVEDX:
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