Fwd: A Black Hole of Patient Safety

Michael.H.Kanter at KP.ORG Michael.H.Kanter at KP.ORG
Wed Sep 14 14:05:25 UTC 2016


As a pathologist, I have also seen the autopsy really become done less 
frequently over the years. It can be a valuable source of finding errors 
(not just diagnostic) but has some limitations that include high cost and 
time involved, potentially biased sample of cases in that consent is 
required and often not obtain, and lack of reimbursement for the 
pathologist.   Most importantly, the autopsy is really designed to only 
detect errors that are discovered when there is a discrepancy between the 
findings at autopsy and the premortem diagnosis and is not really designed 
to see patterns of errors unless one has a good system to collate the 
results of autopsies done over time. . 
         There is a method to still study deaths that we have published 
that we call the e-autopsy that offers some advantages.  One can review a 
much larger sample of deaths,trend results over time, and see patterns in 
care that are less obvious than when reviewing single autopsies.  In many 
cases, if one looks carefully,  the diganostic error is discoverable prior 
to death.   As an example, this method allowed us to realize that we had 
an issue with failure to diagnose and then follow up on aortic aneurysms 
(some AAA were seen by the radiologists but not noticed by the physicians 
taking care of the patient) and so we set up a system to do mitigate this. 
 The e autopsy is limited in that it will not identify diagnostic errors 
that were never discovered prior to death though.  Thus, I believe that 
the regular and e autopsy are complimentary.  Attached is an article on 
the e autopsy process as well as a more recent one focused on deaths from 
colon cancer. 






Michael Kanter, M.D., CPPS
Regional Medical Director of Quality & Clinical Analysis
Southern California Permanente Medical Group
(626) 405-5722 (tie line 8+335)

Executive Vice President,
Chief Quality Officer,
The Permanente Federation

THRIVE By Getting Regular Exercise

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From:   Mark Gusack <gusackm at COMCAST.NET>
To:     IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Date:   09/13/2016 06:43 PM
Subject:        Re: [IMPROVEDX] Fwd: A Black Hole of Patient Safety



Caution: This email came from outside Kaiser Permanente. Do not open 
attachments or click on links if you do not recognize the sender.

Good Evening Everyone:
 
I am a pathologist and I can tell you that, because of the way autopsies 
were supported in hospitals in the past and because of fear of litigation, 
autopsies are few and far in between.  If we are to restart the use of 
autopsies as a means of:
 
Æ  Confirming our diagnoses
Æ  Validating our therapies
Æ  Teaching our students and residents
 
Then we will need to find:
 
Æ  The funding – autopsies are very expensive and labor intensive
Æ  The pathologists willing to do them – they’re messy and did I mention 
labor intensive
Æ  The means of reducing the threat of litigation
 
If we do this, then I can tell you from experience that the results will 
be eye opening.  For example, in most of my autopsies where there has been 
a prior coronary artery bypass graft or two, most are not functional due 
to organized clots and secondary fibrosis of the pericardium that 
obstructs flow.  So that raises the question of what is going on with this 
operation.
 
Everyone have a good rest of the week.
 
Mark Gusack
Staff Pathologist
Huntington VAMC
 
From: Mark Graber [mailto:mark.graber at IMPROVEDIAGNOSIS.ORG] 
Sent: Tuesday, September 13, 2016 10:46 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: [IMPROVEDX] Fwd: A Black Hole of Patient Safety
 
George, I’ve taken the liberty of sharing your email and the link to the 
article with the SIDM listserv audience.  You’ve raised an extremely 
important point, that without autopsies we’ll never know if a cancer death 
was the result of the malignancy or its treatment.  The IOM report 
“Improving Diagnosis in Health Care” called for more autopsies in the US. 
The example you cite is another argument in favor of this recommendation.
 
Thanks for calling this to attention,
 
Mark
 
Mark L Graber MD FACP
Senior Fellow, RTI International
Professor Emeritus, SUNY Stony Brook
President, Society to Improve Diagnosis in Medicine
 
 
 
 
Begin forwarded message:
 
From: George <gdlundberg at gmail.com>
Subject: A Black Hole of Patient Safety
Date: September 13, 2016 at 10:13:37 AM EDT
To: Elizabeth Burton <ecburtonmd at gmail.com>, "Dr. Kaveh Shojania" <
kaveh.shojania at sunnybrook.ca>, "R.E.Horowitz" <r.e.horowitz at ucla.edu>, 
robert.wachter at ucsf.edu
Cc: Mark Graber <mark.graber at improvediagnosis.org>, Paul Epner <
paul.epner at improvediagnosis.org>
Resent-From: <Mark.Graber at Improvediagnosis.org>
 
Good morning,
Please open this 2012 article. I believe that it is open access, full 
text.
http://www.nature.com/bjc/journal/v107/n1/full/bjc2012252a.html
 
In my CollabRx role, I attended an all day program on Targeted Therapy vs 
Immunotherapy in advanced cancer.....all types, last Saturday; many 
academic hotshots. Large numbers of expensive clinical trials inform the 
field. Progression free survival PFS and overall survival OS are the holy 
grail of data. And, in fairness, some PPs did address adverse effects.
Next week I will be publishing a blog at Curious Dr. George by Professor 
Michael Baum of University College London. He argues eloquently that 
Quality of Life is co-equal to Length of Life in those  cancer patients 
who progress beyond curative standard of care (700 000 Americans 
annually). 
One speaker lamented the difficulty of academically studying 
frequency/severity of adverse effects in reports of clinical trials.
Why did autopsies in clinical trials fall off the cliff? How can the 
investigators draw meaningful conclusions about beneficial vs harmful 
effects of these very powerful new agents without autopsies? Was it the 
cancer or the treatment that killed the patient?
Considering the cost of current cancer therapeutics, routine autopsy costs 
would be trivial.
Reactions???
Best,
george
 
 
George D Lundberg, MD
Chief Medical Officer and Editor in Chief, CollabRx, a Rennova Health 
Company
Editor at Large, Medscape
Consulting Professor of Pathology and Health Research and Policy, Stanford
Executive Adviser, Cureus
President and Board Chair, The Lundberg Institute
312 560 0290 cell
@glundberg
gdlundberg at gmail.com
 
Sent from my iPad mini
 
 


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