death certificates and diagnostic error

David Katz d.katz at MAIL.UTORONTO.CA
Tue May 10 00:08:20 UTC 2016

Hi Ruth

I am particular interested in point 3 in your email below. 
Do you have more info on this?

David Katz

> On May 7, 2016, at 10:02 AM, Ruth Ryan <ruthryan at COX.NET> wrote:
> 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.
> Ruth
> Ruth Ryan RN, BSN, MSW, CPHRM
> 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
> 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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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine

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