Leapfrog Group's interest in diagnostic safety

Ruth Ryan ruthryan at COX.NET
Tue Aug 9 14:31:34 UTC 2016


RE: Leapfrog Special Town Hall Call on Diagnostic Error

 

Well worth the time, a brilliant state of the art by Mark Graber and David Newman-Toker, thank you! 

 

And Yes to relevance of delayed referral/failure to refer in dx error, Maureen. 

 

And here is another important one with high probability of harm: delayed or wrong diagnosis 2ndary to fear of calling the chief resident or attending:

 

A practice improvement technique for this is described in Today’s Wall Street Journal, “A Better Safety Net for Young Doctors: A Harvard program coaches new medical residents to ask veteran doctors for help more often, and older doctors to offer that help more readily” at http://www.wsj.com/articles/a-better-safety-net-for-young-doctors-1470661201  Excerpt:

 

Four Harvard Medical School-affiliated hospitals, including Brigham and Women’s Hospital in Boston, have developed new communication standards. They’ve also issued residents a pocket card listing 15 situations that require prompt notification or approval of a senior colleague, such as a patient’s transfer to the intensive-care unit… {Other conditions include A major wound complication, Unplanned intubation, Medication error requiring increased monitoring, A patient’s first blood transfusion, The patient or a nurse requests the attending surgeon be contacted}…

They made these changes in response to research conducted at surgery departments and published in the Annals of Surgery in 2009. This research found that 33% of critical patient events weren’t communicated by residents to attending surgeons.

 

Annals of Surgery article available here: http://www.atulgawande.com/documents/2009AnnSurg--CommunicationPracticeson4HarvardSurgicalServices.pdf

 

See also Editorial: Smink D, Mullen JT. Calling Is Not a Sign of Weakness. Annals of Surgery: March 2016 - Volume 263 - Issue 3 - p 427 doi: 10.1097/SLA.0000000000001611

 

 

Ruth

 

Ruth Ryan RN, BSN, MSW, CPHRM

Medical writer

Risk management/patient safety

Continuing medical education

Telephone (504) 256-8797

Email  <mailto:ruthryan at cox.net> ruthryan at cox.net



 

 

 

 

 

 

From: Maureen Cahill [mailto:MCahill at NCSBN.ORG] 
Sent: Monday, August 08, 2016 8:27 AM
Subject: Re: Leapfrog Group's interest in diagnostic safety

 

Hi Mark, as part of our work in the practice group discussing diagnostic error we are looking further at referral – has anyone to your knowledge discussed a “referring wisely” campaign?  I know it would be an uphill battle to decide guidelines, etc. but it seems a number of closed claims related to diagnostic issues are delay of appropriate referral and there is a good deal of anecdotal discussion about inappropriate referral.  

Maureen

 

Maureen Cahill [Associate] 312.525.3646 (D)  <mailto:mcahill at ncsbn.org> mcahill at ncsbn.org

National Council of State Boards of Nursing (NCSBN) 111 E. Wacker Drive, Ste 2900, Chicago, IL 60601-4277 312.279.1032 (F)  <http://www.ncsbn.org> www.ncsbn.org

Our Mission – NCSBN, Leading in nursing regulation

 

 

 

From: Mark Graber [mailto:graber.mark at GMAIL.COM] 
Sent: Saturday, August 6, 2016 6:56 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG> 
Subject: Re: [IMPROVEDX] Leapfrog Group's interest in diagnostic safety

 

The Leapfrog program on diagnostic error (the slides and an audio recording) can be found here:  There is also a copy of the survey if anyone is interested.

 

Mark 

 

 

http://www.leapfroggroup.org/survey-materials/town-hall-calls

 

 

 

 

On Aug 5, 2016, at 1:36 PM, harry wingate <wingateh at bellsouth.net <mailto:wingateh at bellsouth.net> > wrote:

 

Is there a link to the recording of the teleconference?

 

Thanks

 

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Area Medical Director | EPS Division  <https://www.emcare.com/> EmCare

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On Friday, August 5, 2016 1:01 PM, Mark Graber < <mailto:graber.mark at GMAIL.COM> graber.mark at GMAIL.COM> wrote:

 

 <http://www.leapfroggroup.org/> The Leapfrog Group, an active member of the  <http://www.improvediagnosis.org/?page=CID> Coalition to Improve Diagnosis, is considering a potential future standard regarding diagnostic error on its annual survey of its 1800 member hospitals and organizations.  This past month they sponsored a national teleconference on diagnostic error, presented by David Newman-Toker MD PhD and Mark L Graber, MD.  

 

As part of this program, Leapfrog is encouraging their member organizations to participate in a SIDM survey that will provide hospitals with a ‘check-up’ of where they are at culturally and structurally in their efforts to monitor and reduce diagnostic errors within their hospital.  The SIDM survey will help SIDM and Leapfrog understand the barriers that hospitals are facing in making progress in this important patient safety area.

If your organization is a member of the Leapfrog group, please encourage them to participate in this first-of-its-kind, 10 minute survey:

 

 <https://jhmi.co1.qualtrics.com/SE/?SID=SV_aXD65JbOsyhpJMp> https://jhmi.co1.qualtrics.com/SE/?SID=SV_aXD65JbOsyhpJMp

 

 

Mark L Graber MD FACP
Senior Fellow, RTI International
Professor Emeritus, SUNY Stony Brook
President Society to Improve Diagnosis in Medicine (SIDM)

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