death certificates and diagnostic error

Ruth Ryan ruthryan at COX.NET
Sat May 7 12:07:23 UTC 2016

Very thoughtful Liz, thanks.

I would argue improvement pilot projects have already taken place, some
victorious, and they share common elements. 

1. SURVIVING SEPSIS.ORG analyzed the problems (disease progression outstrips
MD's thought process, labs not set up for rapid lactates, insufficient
attention paid to persistent elevated vital signs, late arrival of lab
results), then crafted solutions (nurse orders sepsis panel automatically
paired with lactate level based on 3-100s vital sign rule, MD receives
sepsis panel results potentially before he or she has thought of the dx),
early intervention rules (central line, ICU bed...) and so forth.
Multidisciplinary team refines and implements, hospital exec and resources
mobilized, baseline is measured, outcomes documented...
2. SUE SHEPHERD'S one-woman campaign to institute universal bilirubin
testing prior to discharge.
3. CRICO's investigation of a tragic dx error caused by resident afraid to
consult the attending...led to multidisciplinary team determining criteria
whereby residents must call attending and attending must answer without
going ballistic. Everybody signed agreement, rules written on back of
residents' ID badges.
4. HARDEEP SINGH et al's mining of EHR data to find and follow up on
positive fecal occult blood tests/other potential cancer signs not followed
up on.


Medical writer
Risk management/patient safety
Continuing medical education
Telephone (504) 256-8797
Email ruthryan at

-----Original Message-----
From: Elizabeth Regan [mailto:lizregan53 at GMAIL.COM] 
Sent: Friday, May 06, 2016 11:24 AM
Subject: death certificates and diagnostic error

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

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

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

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?  


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