[Spam] [IMPROVEDX] Death Certificates

Thu May 5 09:27:08 UTC 2016

Nothing has ever happened as a result of one cause.

·     Direct Causation

An inescapable fact is thatevery effect/ phenomenon/ result/ consequence/ outcome/error is the direct resultof a set of conditions, behaviors, actions, and/or inactions. One condition,behavior, action, or inaction cannot be the causation of any effect/phenomenon/ result/ consequence/ outcome/error in the absence of at least oneother pre-existing predisposing set-up condition, behavior, action, and/orinaction[1].Thus one should not ask why, but rather, “What is the set of conditions, behaviors,actions, and/or inactions that directly resulted in the effect?

Observation: The causation ofan intersection collision involves much more than running a stop sign.

Observation: The causationof the Challenger accident involved much more than low launch temperature.

Observation: When one istold that X was caused by Y, ask “What were the other conditions, behaviors,actions, and/or inactions that were necessary for the occurrence of X?”

Observation: “The Five Whys”naively and simplistically ignores this inescapable fact[2].

·     Adequacy of Causation[3]

An inescapable fact isthat the specified stated causation of an effect/ phenomenon/ result/consequence/ outcome is not complete/ adequate unless it explains all of theattributes of the effect/ phenomenon/ result/ consequence/ outcome. If thestated causation does not explain all of the attributes of the harm/ harmfulitem, there must be something missing or in error.

Observation: Every event isits own ”Perfect Storm[4]”in the sense that if any part of the causation had been different the resultantharm would be different.

Observation: Any condition,behavior, action, or inaction that affected one or more attributes of theharmful result was part of the causation of the result.

Observation: Any condition,behavior, action, or inaction that affected one or more attributes of theharmful result directly, i.e., without intermediation, was part of the direct causationof the result.


[1] Forexample, a spark will not result in an explosion unless it is sufficientlyclose to an explosive item.

[2] https://en.wikipedia.org/wiki/5_Whys

[3] Refinedat Update 3.0

[4] https://en.wikipedia.org/wiki/Perfect_storm

 Take care,
Bill Corcoran

William  R. Corcoran, Ph.D., P.E.
21 Broadleaf Circle
Windsor, CT 06095-1634
William.R.Corcoran at 1959.USNA.com


    On Wednesday, May 4, 2016 11:24 PM, robert bell <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG> wrote:

 It is not common practice to put either Error in Diagnosis, or Error in Medicine on a death certificate. They seem to require some kind of diagnosis even if it may be incorrect.
Could this Society change that with action and recommendations or would you have to first change litigation law to achieve that?
Are there any other solutions that would be acceptable? 
This would seem to be part of that data lack that plagues the Error in Medicine discipline.  

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

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