In Search of a Common Definition of Dx Error

Elias Peter pheski69 at GMAIL.COM
Mon May 9 12:59:01 UTC 2016


I enjoyed - and agree with - your general analysis and the importance of specifying that errors include both acts of commission and omission. My statement was not meant to minimize the importance of errors of omissions, though I omitted any specific mention. 

The errors I have been closest to and had the best opportunity to study have been those I have made, those made by my close colleagues and office staff, and those involving my patients. I have not made a scientific study, but the commonest pattern I see is that of  intelligent, hard-working individuals who are committed to patients doing something (or not doing something) because at that particular moment it makes the most sense or appears to be the best option.  One of the common threads is that a better option was available, but would have involved either significant extra effort or actually stepping out of protocol and doing something the system had no machinery to support.

A good RCA will assess the context of the action (or inaction) to determine why that decision was made, with a goal of changing the context to make a better decision more likely in the future. By a series of successive approximations, this can result in a ‘self-healing’ system. My experience has been that the RCA fulfills the regulatory requirement of having a process to assess errors and results in an admonition to individuals to do better but no systemic change. 

For those who prefer story-telling and examples, here is a real incident. A woman is evaluated by her PCP for asymptomatic hematuria. The evaluation finds no renal disease but identifies a complex adnexal mass. The patient is informed and told further testing is needed, but declines pursuit of this by her PCP and prefers to see her GYN. Both work in the same system, though in different buildings and using different electronic record systems. The PCP faxes the radiologic study to the GYN office with a copy of the office notes about the issue, where it is reviewed by the gynecologist and a notation is made to pursue it. Over a period of three years, the patient is seen several times in each office by several different people (but not the PCP) but the adnexal abnormality is not pursued. The patient assumes that no news is good news and doesn’t ask why she hasn’t heard, until she presents with abdominal pain and a mass that turns out to include an ovarian carcinoma. The RCA identifies a series of information management and communication deficits, a number of systemic change suggestions are made, and the individuals involved are advised to pay more attention to closing the loop. None of the systemic changes are pursued and the case is not presented for its educational value in the institution. 

I wish I could say this is unusual or an outlier, but my experience has been that this is pretty typical. From my perspective,  the issue is how to get institutions to commit to change based on the RCA.

Peter



> On 2016.05.09, at 8:16 AM, Bob Latino <blatino at reliability.com> wrote:
> 
> Peter, I have really enjoyed reading your posts and your open-mindedness in this diagnosis error debate.
>  
> I think that what is necessary is a common understanding of what an error is.  I believe much of the back-and-forth on this forum is related to the lack of common understanding about what an error is (there apparently is no universally accepted definition), how to identify, report, record and investigate them and finally how to learn from them.  It is very hard to identify what we cannot define.
>  
> 'Error' is typically much more involved than with a single decision-maker.  An 'error' typically is a decision that ultimately results in an unintended outcome.  Does this mean 'the' root cause is due solely to the triggering poor decision?  This is not my experience as a career investigator/root cause analyst.
>  
> You mention below:
> The mindset that sees errors as an issue related to the actions of individuals (errors of commission).
> I would like to add as a suggestion that included in 'errors' are inactions (decisions not to act or errors of omission).  In both cases these are decision errors.
> Effectively, at the decision level we are in the minds of the decision-maker.  At that point, there is a derived rational going on where a collection of information/conditions is being processed.  Based on this aggregation of information /conditions, the decision-maker will choose to act or not act in a certain manner.  I will just use our cause labeling for description's sake.  The decision itself is what we would refer to as a 'Human Root Cause'. Various RCA approaches and regulatory agencies will use different labels.
> The result of a poor decision will trigger a series of observable, cause-and-effect relationships.  These are the consequences of the decision or what we call Physical Root Causes.  There are normally many signals before an 'error' will actually cause harm.  Oftentimes along this cause-and-effect chain, we have astute personnel who break the chain and do not allow it to complete (resulting in harm, injury, excessive costs, regulatory violation and the like).  Breaking the error chain is often characterized as a 'near miss', 'close call' or 'good catch'.  Absent our ability to break the error chain, we end up with an undesirable outcome.  This often means an RCA will HAVE to be done and usually involve many departments and agencies (this is strictly a reactive use of RCA).
> The 'seed' of the undesirable outcome is the decision error.
> We must now understand the rationale for the poor decision.  Why did the decision-maker believe at the time of the decision, that it was correct?  To me, that is what RCA is all about.  In the mind of the decision-maker, they felt the decision was correct.  The only time this is not the case is when the decision was made with malice and intent, which is sabotage and a criminal event (which is a fraction of a percent of the time).
> The rationale for the decision is what we refer to as Latent Root Causes or Organizational System Related.  These are our policies, procedures, evolved practices, training systems, purchasing systems, lack of management oversight/lack of enforcement of existing systems, human factors and human performance systems, environmental conditions and the like.  When considering all of these systemic factors, we ultimately make a decision to do or not do something.  While seems like this is a long and drawn out process, typically it is minutes or even seconds in which a decision is required.
> In true RCA, if we do our jobs properly, correcting the flawed systems will change the decision behaviors in the future. Below is a quick graphic to summarize these points.
> <image001.jpg>
> While a decision-error may trigger this unintended path, other errors along the way typically occur.  As this error chain progresses, there are normally numerous chances to break the chain.  As these 'symptoms' are observed, we have the opportunity to take action to break the chain and often do not.
> When we break such decision-making down to its most basic understanding, either
> 1) the intended plan is a good plan that we do not follow or
> 2) the intended plan is a bad plan that we do follow. 
> In either of these paths there are errors associated with our ability to prepare an adequate plan as well as our ability to execute that plan.  While we typically try and attach an error to a single individual, the reality is there may be many errors along the same error path.
> I have found over past decades of doing these RCA's in HC, that many on the front line personnel are quite capable and understanding of their specific jobs. However, I find a general lack of understanding of the big picture, the 'systems' in which they work.  This lack of systems understanding contributes to many (if not most) undesirable outcomes.
> Most HC organizations do 'RCA' simply to be compliant and therefore do it for the wrong reasons (checklist mentality).  They do not understand how to leverage the learning across the system, so that the revealed 'stories' can be shared in their educational systems.  When personnel are exposed to these 'stories', they see how certain well-intended decisions played out in a manner not intended.  This story, sticks in their minds and if they ever see such conditions queue up in their environment, they will remember that story and ensure the same outcomes do not occur.
> Sorry for the dissertation but this comes from 31 years of doing RCA and being frustrated with organizations who apply it strictly to be compliant, when compliance unfortunately has little to do with actual measureable, patient safety.
> Bob Latino
>  
> Robert J. Latino, CEO
> Reliability Center, Inc.
> 1.800.457.0645
> blatino at reliability.com
> www.reliability.com
>  
> From: Elias Peter [mailto:pheski69 at GMAIL.COM] 
> Sent: Sunday, May 08, 2016 8:12 AM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: Re: [IMPROVEDX] In Search of a Common Definition of Dx Error
>  
> 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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