CRICO Resident Attending Communications Project FW: death certificates and diagnostic error

Ruth Ryan ruthryan at COX.NET
Tue May 10 18:09:38 UTC 2016


In response to several requests for more info on the CRICO Project
Resident-Attending Communications, Here is one link: 
https://www.rmf.harvard.edu/Clinician-Resources/Article/2009/Triggers-for-Re
sident-to-Attending-Communication

I've requested any additional info/resources on the project and will share.

Ruth

Ruth Ryan RN, BSN, MSW, CPHRM
Medical writer
Risk management/patient safety
Continuing medical education
Telephone (504) 256-8797
Email ruthryan at cox.net




-----Original Message-----
From: David Katz [mailto:d.katz at MAIL.UTORONTO.CA] 
Sent: Monday, May 09, 2016 7:08 PM
Subject: Re: death certificates and diagnostic error

Hi Ruth

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

Thanks
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 cox.net
> 
> 
> 
> -----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 
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