death certificates

Elias Peter pheski69 at GMAIL.COM
Fri May 6 17:17:32 UTC 2016


Thank you for this. 

During nearly 40 years as a PCP, I have yet to see a single health care RCA that was more than a charade, done to fulfill the need to document a process. I have yet to see a RCA result in a combination of systemic change and monitoring to measure the impact of that change.

My only complaint about what you said or how you said it, is that I would talk about the ‘other’ high hazard industries, rather than differentiate between health care and high-hazard industries.

Peter

> On 2016.05.06, at 7:04 AM, Bob Latino <blatino at RELIABILITY.COM> wrote:
> 
> An effective and true RCA doesn't end with the human being, but begins with it. 
>  
> Unless the poor decision made involved intent with malice (sabotage), who made the decision should not be the focus of the RCA.  'Why' they thought it was the right decision at the time, is what an RCA should be looking for.  The reasoning used to make the decision at that time, is what is important.  This will uncover the systemic issues that need to be addressed to correct the behavior of not only the decision-maker in that case, but everyone else who is reliant on using that existing system to make better decisions.
>  
> The breadth and depth of an RCA in the high hazard industries is light years ahead of RCAs in an average healthcare setting.  In my experience, RCA in healthcare is a checklist function to continue to get CMS funding, not to demonstrate any measurable improvement in patient safety.  Most all 6000 hospitals in the U.S. are accredited (including their RCA programs), yet the deaths due to medical error/hospital error continue to rise year after year.  One can deduce that compliance does not necessarily relate to measureable patient safety.
>  
> The high hazard industries like nuclear, chemicals, petro-chemicals, etc., understand the role of human performance (not just human factors) to an investigation.  I do not find this depth of understanding of human reasoning in the healthcare space, nor a desire to obtain that depth or an incentive to do so.  To me, this demonstrates that understanding such reasoning is not a leadership priority as long as the money flows.  I am speaking in generalities of course, because like everywhere else, there are always pockets of excellence.
>  
> Dr. Corcoran will recognize this from other forums we participate on, but it applies to any industry:
>  
> "We never seem to have the time and budget to do things right, but we always seem to have the time and budget to do them again!"
>  
>  
>  
> Robert J. Latino, CEO
> Reliability Center, Inc.
> 1.800.457.0645
> blatino at reliability.com
> www.reliability.com
>  
> From: Carroll, Thomas [mailto:Thomas_Carroll at URMC.ROCHESTER.EDU] 
> Sent: Thursday, May 05, 2016 4:48 PM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: Re: [IMPROVEDX] death certificates
>  
> 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 <mailto:lberlin at LIVE.COM>] 
> Sent: Thursday, May 05, 2016 4:19 PM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto: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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