Death Certificates

Phillip Benton, MD, JD pgbentonmd at AOL.COM
Thu May 5 23:58:14 UTC 2016


Joe,

Sorry about your mother, but this shows what we physicians don't see until we or a family member are on the other side of the illness/treatment event. The extension of this is that today nearly always the person or family leading causes against medical error are those who have lost loved ones to preventable error. Every chapter in Charles Kenney's The Best Practice (2008) begins with such a story

You don't even see it, or refuse to believe it, until it hits you.
Phil Benton


 



 


 



-----Original Message-----
From: Joe Graedon <jgraedon at GMAIL.COM>
To: IMPROVEDX <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Sent: Thu, May 5, 2016 6:16 pm
Subject: Re: [IMPROVEDX] Death Certificates

This is for Geri Amori,

So…a surgeon cuts a critical artery during a “routine” procedure. The patient bleeds out and dies of cardiac arrest. The death certificate says “cardiac arrest” is the cause of death, even though the actual reason for the cardiac arrest was a surgical mistake. 

Another example: A patient is given a deadly drug interaction in the hospital that leads to serotonin syndrome shortly after the removal of a sheath from a femoral artery (following angioplasty). The patient thrashes uncontrollably for hours as a result of the drug interaction and dies the next morning. The death certificate states cause of death: “retroperitoneal hemorrhage.” There is no mention of the drug interaction that led to the uncontrollable muscle contraction that led to the bleeding that led to the hypotension that led to the death. 

By the way, that second case is exactly what happened to my mother at a major medical center.

Joe

> On May 5, 2016, at 3:20 PM, Jackson, Brian <brian.jackson at ARUPLAB.COM> wrote:
> 
> I think you're making a cultural argument more than a scientific one. (Which doesn't make it wrong by the way).
> 
> Death certificates are supposed to list the immediate "cause" rather than the immediate physiologic mechanism. For example MI and lung cancer are appropriate causes of death to list on a certificate. Cardiac arrest and respiratory failure are not. (Disclaimer: I haven't done autopsies or death certificates for almost 20 years so my knowledge is a bit rusty here.)
> 
> --Brian
> 
> Sent from my iPhone
> 
> On May 5, 2016, at 12:12 PM, Geri Amori <gamori at COVERYS.COM<mailto:gamori at coverys.com>> wrote:
> 
> I am following this discussion with interest and curiosity. Perhaps what I am going to say will not be popular, but it feels like it needs to be said. I am not certain there would be any benefit to putting “error” on a death certificate. Ultimately, it was NOT the error that caused the death, but the physical response to the possible error. Putting “error” in the death certificate is like saying typing is the cause of erroneous information in the news. My point is that labeling the cause of actual physical death as “error” feels and sounds punitive and indirect. We MUST find out the cause of errors so they happen less frequently. (We are striving to make them happen not-at-all.) Nevertheless, we will never stop death. The rate remains 100% globally. I would NOT want my death certificate to label and blame another person for all eternity. I prefer to go to my grave in a state of humane understanding. Nonetheless, I would still want for those who remain to investigate what happened to ensure it doesn’t happen to another.
> 
> Geri Amori, PhD, ARM, CPHRM, DFASHRM
> Vice President, Academic Affairs
> P: 617.526.0360
> 
> C: 802.238.5652
> 
> 
> COVERYS
> One Financial Center
> Boston, MA 02111
> www.coverys.com<http://www.coverys.com/>
> 1.800.225.6168
> 
> From: Pete Dayton [mailto:pdayton at PTWFL.COM]
> Sent: Thursday, May 05, 2016 12:44 PM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at list.improvediagnosis.org>
> Subject: Re: [IMPROVEDX] Death Certificates
> 
> Hi folks, my first post…It probably won’t be used as a cause of death as this is sometimes subjective unless one performs a formal autopsy. Secondly malpractice risk, who would assign that liability willingly to themselves on a death certificate, it’s human nature ? Lastly people dying of multisystem disease sometimes die of multiple simultaneous issues all of which may not have been thoroughly investigated. Is that an error, slip or malfeasance? Calling a PE a rib bruise is one thing, but my experience is that it is seldom that clear. Hindsight is always 20:20 and yes I agree the Errors are happening at an alarming rate. Stop paying doctors for piece work and stop depending on the EMR to mention every possible drug interaction east of Eden , make the docs be Doctors! High volume , alarm fatigue and distractions all clearly recognized as potential opportunities for error in aviation and not in medicine. Docs need cockpit resource management , RCM , skills and need to slow down, study the drugs they prescribe well, see fewer patients , especially complex internal medicine patients, take better histories, listen to patients, become astute at physical diagnosis again and enjoy the practice of medicine! Yes they will make less money but pay them for outcomes not volume and this will improve. I don’t think we should rely on the ERM and the internet for everything. I have used an EMR for 10 + years and it is helpful but a double edge sword. I teach medical students and make them get their heads out of their phones and actually learn the stuff. The harder one works to solve the problem the better the lesson. Make answers too easy and I think you lose a lot. Students come through their general surgery rotations come to my GYN service and can’t write post op orders because of automated order sets. When I see them we pull a blank piece of paper out of the printer and they write the orders. It is amazing the deer in the headlight looks I get!
> 
> Just my 2 cents
> 
> Love your show Joe!
> 
> Peter M. Dayton MD
> Medical Director of Patient Safety and Quality
> Martin Health Systems
> 1815 Kanner Highway
> Stuart, FL 34994
> 772-288-2992 Office
> 772-285-4020 Cell
> 772-288-2999 fax
> pdayton at ptwfl.com<mailto:pdayton at ptwfl.com>
> I Peter 3:15
> 
> 
> 
> From: Joe Graedon [mailto:jgraedon at GMAIL.COM]
> Sent: Thursday, May 05, 2016 8:36 AM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> Subject: Re: [IMPROVEDX] Death Certificates
> 
> This is a very interesting concept.
> 
> Just out of curiosity, has anyone ever asked the question or sought an answer to the question:
> 
> How many times does "Error in Diagnosis" show up on death certificates? If I were a betting person I would guess rare to never.
> 
> As to the second "Error in Medicine" I would guess never.
> 
> To change that one would need to change the culture of medicine.
> 
> Joe
> 
> Sent from my iPad
> 
> On May 4, 2016, at 11:11 PM, robert bell <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG<mailto: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.
> 
> 
> 
> ________________________________
> 
> Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto: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<mailto: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/
> 
> ________________________________
> 
> Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto: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<mailto: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/
> 
> ________________________________
> 
> Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto: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<mailto: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/
> 
> ________________________________
> This email and any files transmitted with it are intended only for the person or entity to which it is addressed and may contain confidential and/or privileged material. If you received this email in error, please contact the sender immediately and delete this email from your system. If you are not the named addressee, you should not disseminate, distribute, print, or copy the email, or take any action in reliance on its contents.
> 
> ________________________________
> 
> Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto: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<mailto: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/
> 
> -------------------------------------------------------------------
> The information transmitted by this e-mail and any included
> attachments are from ARUP Laboratories and are intended only for the
> recipient. The information contained in this message is confidential
> and may constitute inside or non-public information under
> international, federal, or state securities laws, or protected health
> information and is intended only for the use of the recipient.
> Unauthorized forwarding, printing, copying, distributing, or use of
> such information is strictly prohibited and may be unlawful. If you
> are not the intended recipient, please promptly delete this e-mail
> and notify the sender of the delivery error or you may call ARUP
> Laboratories Compliance Hot Line in Salt Lake City, Utah USA at (+1
> (800) 522-2787 ext. 2100
> 
> 
> 
> 
> 
> 
> 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>






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>






Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine

HTML Version:
URL: <../attachments/20160505/965bd3bc/attachment.html>


More information about the Test mailing list