In Search of a Common Definition of Dx Error

Elias Peter pheski69 at GMAIL.COM
Mon May 9 13:29:45 UTC 2016


I’m sure others have written about this, and perhaps done research, but here are some thoughts:

Our hard-wired need for certainty and clarity is powerful.
We are also hard-wired to be more responsive to short-term than long-term consequences. (Generally a feature rather than a bug, but perhaps not in this situation.) Short term, we get great benefit out of pretending we are right, though the long-term consequences are pretty bad.
We are taught starting quite early that being wrong is a bad thing, and we internalize this and develop a myriad of personal (internal) and systemic (external) ways to avoid being labeled as wrong.
Though it has improved since my training years, medical education reinforces the error=bad mind set and does not teach any systemic approaches to minimizing error.
The greater the stakes, the scarier any error becomes. This should push us to reduce errors, but unfortunately it often pushes us to avoid being caught in errors. (See next bullet point.)
It is easier to avoid being labeled wrong than it is to avoid being wrong. (The old joke is: It’s not what you do that counts, it’s what you get caught doing.)
The culture in medicine has long been centered on the individual clinician rather than on the system, making scapegoating a default approach to errors and bad outcomes.
We (science in general and medicine in specific) have spent the last 50 years extolling our power and virtue - and glossing over our weaknesses. (Humility makes it easier to recognize and address error than arrogance.) This is not just an institutional or commercial marketing issue. Listen to any clinician talk to patients. You will hear unsupportable statements all day long: Your stress test is negative so this isn’t heart disease. That medicine doesn’t cause that side effect. Taking this medication is important to keep you from having a heart attack. Your child with strep stops being contagious 24 hours after starting antibiotics. We have trained ourselves, our patients, and our society to think of us as far more ‘right’ and powerful than the evidence supports, but the Emperor is seriously underdressed.
Those who run institutions have little direct contact with patients in a caring capacity and quite naturally are more inclined to see the institution as their responsibility than the (to them theoretical) patient in the room with me.
Here we come full circle to my first point. Both patients and health care professionals are hard-wired to need certainty and clarity.

That’s my quick and dirty answer, which I happily label as incomplete, tentative, full of omissions and false emphasis - but a place to start talking?

FWIW, when I work with FP residents I emphasize uncertainty and the provisional nature of what we do. They often look to me or other attendings for The Answer.  I like to reply by suggesting we develop a hypothesis for what is going on and what we should do and talk about how to test it.  rarely use the term diagnosis and hammer at them to recognize that the diagnosis of JRA tells them little about the patient in the same way that the label boreal chickadee tells them little about the bird. Once they have presented their assessment, I ask them what information that have discarded or devalued to reach this assessment. I ask what other options they have considered. I ask what they will look for as evidence they are wrong (more effective than asking what will tell them they are right - they are already good at that).

Peter





> On 2016.05.09, at 7:53 AM, DR WILLIAM CORCORAN <williamcorcoran at SBCGLOBAL.NET> wrote:
> 
> Dr. Elias,
> 
> Your message that, " ...we cannot work on fixing something that we are afraid to talk about."was an eye-opener for me.
> 
> There are many harmful conditions, behaviors, actions, and inactions that are part of the causation of the chilling effects that suppress expressions of concern in many endeavors, including health care.
> 
> What are the harmful conditions, behaviors, actions, and inactions that result in being afraid to talk about the patient harm epidemic?
>  
> Take care,
>  
> Bill Corcoran
> 
>  
> William  R. Corcoran, Ph.D., P.E.
> 21 Broadleaf Circle
> Windsor, CT 06095-1634
> 860-285-8779
> William.R.Corcoran at 1959.USNA.com
> http://www.linkedin.com/in/williamcorcoranphdpe <http://www.linkedin.com/in/williamcorcoranphdpe>
> https://www.box.com/shared/kfxg1lt9dh 
> 
> 
> 
> On Sunday, May 8, 2016 10:28 PM, Elias Peter <pheski69 at GMAIL.COM> wrote:
> 
> 
> I believe there are two foundational barriers to effective work on safety:
> 
> The mindset that sees errors as an issue related to the actions of individuals.
> The focus of institutions on institutional health and success rather than on patient outcomes.
> 
> We need to frame safety as something the entire team owns, reserve punishment for willful malfeasance, reward the entire team much more than individuals for success, and accept that we cannot work on fixing something that we are afraid to talk about.
> 
> My frame of reference local action in small organizations, like a primary care practice with 10 clinicians, various community volunteer groups, teaching in a residency setting. I have found this approach to be surprisingly possible and effective at this smaller scale. Getting from here to there on a large scale? I wish I had an answer, but sharing ideas and reinforcing commitment in groups like this makes sense to me, as does the benefit of each of us making as much local change as we can.
> 
> Peter Elias, MD 
> 
>> On 2016.05.06, at 1:36 PM, Vic Nicholls <nichollsvi2 at GMAIL.COM <mailto:nichollsvi2 at GMAIL.COM>> wrote:
>> 
>> List members another something for you to consider when we talk about medical errors/mistakes/whatever.
>> 
>> I submit that it isn't just deaths we need to look at. In my case multiple records mistakes are made (for starters). Everyone gets into a huff & deny/defend when I ask to fix them. I've yet to sue any one, not threatening lawyers either. I'm saying fix this in a way that doctors who are doing my treatment forward can make the best decisions/judgement on my care. Work together as a team.
>> 
>> How are we going to help other doctors when they have to wade through screens/pages of stuff that isn't true or they don't know what is and what isn't? Either they get wrong assumptions or have to start from scratch.
>> 
>> WHY are doctors doing this to each other (much less patients)? Why hurt your own?? Surgeons eat their own and look where it got them.  :)
>> 
>> Seriously, the attitude of deny/defend and hide only makes things worse. Why? Because the mistakes are pretty obvious and the attitude towards fixing them, to listening to the patient, only gives the medical profession a worse black in the eye. If you think, like I do, admin are stiffing you in the back in many ways, this is another way they help to fuel major distrust in doctors AND the system. That means doctors who are in this list (and others I know) who are trying to figure out how/what/when/why for errors. When I say the system, it is doctors who are the face of it.
>> 
>> And yes, I've told admin to get front and center for their mistakes, and they copped out. Every time. Don't think we don't know some of your pain.
>> 
>> Consider that we could have the health care profession and patients working together, who would be a more efficient, cost cutting, and you'd get the better reputation for dealing with the problems, without all that (overbloating, $$$$ wasting IMO) admin.
>> 
>> Victoria
>> 
>> 
>> On 5/6/2016 10:55 AM, Leonard Berlin wrote:
>>> Over the past several days I have enjoyed reading the long list of commentaries submitted by very bright and caring physicians.  medical-associated people,  and researchers,  on the subject of the frequency of medical errors and their  role in causing death of patients. This has led me to conclude the following undeniable */_fact:_/*
>>> 
>>> _*NOBODY KNOWS HOW MANY MEDICAL ERRORS ARE COMMITTED, AND NOBODY KNOWS HOW MANY PEOPLE ARE KILLED BY MEDICAL ERRORS!*_
>>> **
>>> The articles by Makary and others that calculate numbers related to medical errors and patient injury _are nothing more than statistical projections,  extrapolations, estimates, and conjectures. _
>>> 
>>> Makary, Johns Hopkins, and the BMJ got great international headlines by "estimating" that 251,454 patients die of medical mistakes annually. Needless to say, the word "estimating" doesn't appear very much,  if at all, in the headlines and limited text proclaimed  in newspaper and TV news reports.
>>> 
>>> Today, physicians  in all specialties are presumably  practicing   "evidence-based-medicine."
>>> 
>>> When it comes to medical errors, there is no "evidence!"
>>> 
>>> Yes, focusing attention on medical errors is certainly productive, and indeed encourages all of us to improve medical care safety and reduce errors.  And clearly, supporting organizations such as  SIDM is a step in the right direction.
>>> 
>>> We should be transparent to the public, but frightening everyone and causing them to lose confidence in their physicians is counterproductive. Our message to the public should be an honest one:  MEDICAL ERRORS DO OCCUR, BUT WE DO NOT KNOW, AND WILL NEVER KNOW, HOW MANY PATIENTS DIE DUE TO A MEDICAL ERROR; HOWEVER, WE ARE WORKING ON WAYS TO REDUCE THEM.
>>> 
>> 
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