death certificates and diagnostic error

Erika Brown mayor at COLONTOWN.ORG
Sat May 7 00:22:38 UTC 2016


I am in complete agreement with Peggy: Let the patient in on the whole deal.
The patient not only has a right but a duty to help with the process.
Peggy mentions the swapped, mislabeled scans.  Not only did I have a failed
first colonscopy, but the second process (barium enema xray) produced a
report to my doctor (not the actual image) that proclaimed that my test was
"unremarkable".
Six months later (after a successful scope), the surgeon managed to find
the CORRECT image of that test.  (Imagine the poor person who was told that
they had colon cancer....incorrectly.)
Even I could see that big, fat tumor that was obstructing my ascending
colon 6 months prior to right then.  (I was shown it by my furious surgeon.)
My surgery delivered the staging of iiic....much further down the staging
road than I should have been.
I should be dead.
I'm just lucky.
I really should be dead.

Erika Hanson Brown
Chief Engagement Officer (CEO)
Patient Action League LLC

Founding Mayor: COLONTOWN – *Where Experience Reaches Out*
Washington, DC
703.575.8585
303.780.9111 (cell)
erika at patientleague.com
mayor at colontown.org

Founding Mayor: COLONTOWN - the community of CRC patients, survivors &
family members
See the current COLONTOWN Newspaper!
http://www.chris4life.org/content_documents/14/CTnews.pdf



On Fri, May 6, 2016 at 8:03 PM, Peggy Zuckerman <peggyzuckerman at gmail.com>
wrote:

> Though this is complex problem, there are some simple steps to be taken
> immediately.  The first is to provide the patient his record for
> review--and correction--at every appointment.  THere are amazing stories of
> swapped records, obvious errors, imput diagnosis that are shown to be
> incorrect, but remain in the record and on and on.
>
> Next is to provide all the test, and all the imaging to patient at the
> same time as to their doctors.  Again, errors in being shown someone else's
> scans, name is incorrect, images compared to the wrong previous CT, etc.
>
> This also sets the expectation that the patient has a role in diagnosis.
> He certainly carries the greatest risk; let him help in this simple task.
>
> Peggy Zuckerman
>
> Peggy Zuckerman
> www.peggyRCC.com
>
> On Fri, May 6, 2016 at 9:23 AM, Elizabeth Regan <lizregan53 at gmail.com>
> wrote:
>
>> This is such a painful topic for conscientious physicians who struggle to
>> do the best.  I cringe thinking about errors I have made in my 30+ years of
>> practice and do not revel in the thought of more exposure or tracking.
>>
>> However, as a human being who depends on the careful work of physicians
>> and has way too many stories of medical diagnostic error in my friends,
>> family and my own encounters with the medical profession I feel very
>> strongly that we need to characterize the problem and make incremental
>> progress to reduce it.
>>
>> I have no enthusiasm for electronic medical records in the fight.  They
>> are full of bad data due to careless data entry, lack of verification and
>> no effort to update.  I see lots of copy/pasting of wrong information.
>>
>> EMRs have not come close to the early promises that they would help us
>> generate comprehensive differential diagnoses or the ability to sort
>> through enormous amount of data.  You can make a table of lab results.  You
>> can see the current medications ( with lots of errors).
>>
>> What the EMR does not foster is thoughtful integration of symptoms, signs
>> and test results.  It does not remind physicians of basic clinical
>> epidemiology principles in interpreting test results.
>>
>> Comment on aviation - many years as pilot and copilot.  If you screw up -
>> you are still in trouble.
>>
>> Individuals that society entrusts are expected to be perfect in some
>> sense.
>>
>> Punitive actions are a problem for the physician who is trying hard to do
>> right, but for the subset of careless people you need to have boundaries
>> and consequences.
>>
>> I think it could be easier for all if we were able to look at these
>> errors as the common events that they are and dispassionately try to reduce
>> them.  The current, highly charged,  guilty or not guilty system leads to
>> lies, denial and continued problems.  So there need to be several
>> directions taken.
>>
>> Maybe within organizations and medical groups there could be protected
>> analysis of errors with the goal of quality improvement.  Perhaps an
>> initiative taken as a pilot project to evaluate whether tracking and
>> careful analysis of root causes would help.  Maybe a value  based
>> educational program as another pilot initiative - what would you want to
>> teach physicians about diagnostic error prevention.  How to structure a
>> practice to prevent such errors.  regular time for colleagues to sit down
>> and review cases - tough to do when there are patients waiting or you need
>> to see more in order to make salaries and bills.
>>
>> Are there health care partners who would gain from reductions in errors.
>> Would they fund some pilot projects
>>
>> Do we have enough research to lead/design a pilot improvement project?
>>
>> Liz
>>
>>
>>
>>
>>
>> Moderator: David Meyers, Board Member, Society to Improve Diagnosis in
>> Medicine
>>
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>>
>
>
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> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
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>
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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