death certificates

Elias Peter pheski69 at GMAIL.COM
Thu May 5 23:50:33 UTC 2016


As long as there is the default attitude that ‘someone is at fault’ we will never make much progress. The default attitude HAS to be that everyone is doing the best they can with the skills and training and system available, and that the FIRST (and second and third…) thing to look at with an error, or a near-error, is how to we change the system to make this error less likely to happen next time.

Shooting the person who nicks an artery or prescribes 10x the correct dose of a medication does not prevent a recurrence.  Public hanging would prevent lots of behavior, but since most behavior is not problematic, the balance of harm versus benefit from public hanging is terrible.

The best thing to do should also be the easiest and most obvious thing to do, and we need to think of most errors as a need to make a system that does this.

Peter


> On 2016.05.05, at 4:47 PM, Carroll, Thomas <Thomas_Carroll at URMC.ROCHESTER.EDU> wrote:
> 
> I wonder the same thing.  If we were to go by strict Bayesian logic from one pretest/post-test probability set to the next to diagnose something, the final diagnosis would always be associated with a final post-test probability of < 100%.  This means that there would always be someone, somewhere who was “misdiagnosed.”  It is this fact that makes me uncomfortable with what sometimes seems to be an attitude that someone is at fault anytime the retrospectoscope identifies a “misdiagnosis.”
>  
> This is not to say that we can’t do better, just something to keep in mind.
>  
> Thomas M. Carroll M.D., Ph.D.
> Assistant Professor, General Medicine & Palliative Care
> University of Rochester
> thomas_carroll at urmc.rochester.edu <mailto:thomas_carroll at urmc.rochester.edu>
> Pager 5-1616 #3872
> Tel: 585-275-7424 (General Medicine Office)
> Tel: 585-273-1154 (Palliative Care Office)
>  
> From: Leonard Berlin [mailto:lberlin at LIVE.COM] 
> Sent: Thursday, May 05, 2016 4:19 PM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: Re: [IMPROVEDX] death certificates
>  
> This makes one wonder whether medical errors really are the third most common cause of deaths!
>  
> With all the studies out there claiming frequent fatal medical  errors, one has to wonder whether in each case the medical chart was carefully evaluated in detail to determine beyond reasonable doubt that the death was due to a medical error.......
>  
> Lenny
>  
> > Date: Thu, 5 May 2016 11:39:04 -0600
> > From: lizregan53 at GMAIL.COM <mailto:lizregan53 at GMAIL.COM>
> > Subject: [IMPROVEDX] death certificates
> > To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> > 
> > I would not favor adding medical error to death certificates for a variety of reasons but the chief one being that it is so hard to define and while is obvious to those who want to see improvement, it is less obvious to those who want to avoid the concept. At the point where there is broader consensus on how to identify and reduce medical error (especially diagnostic error) I think it will be easier to record and track the event.
> > 
> > I believe strongly that it is critical to do that, but we are not there yet.
> > 
> > I have just completed a project to adjudicate cause of death in nearly a 1000 deaths for a large cohort study. The project involves reviewing both death certificates and medical records. At that level of review I did not see evidence of diagnostic error or other errors. Now that I consider the project in light of this discussion - I guess that is interesting.
> > 
> > I don’t interpret this to mean that none of those subjects experienced error, but rather to reflect on the invisibility of error in our record keeping.
> > 
> > I wonder about the feasibility of re-reviewing the data with a more critical eye and finding more. However, I don’t really think I would find much.
> > 
> > Liz Regan
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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