A Black Hole of Patient Safety

Maureen Cahill MCahill at NCSBN.ORG
Wed Sep 14 13:46:28 UTC 2016


I seem to recall that Mayo’s quality officer does a death review of every case that occurs in the facility – without autopsy but sort of a records autopsy….would that suffice?
Maureen

Maureen Cahill [Associate] 312.525.3646 (D) mcahill at ncsbn.org<mailto:mcahill at ncsbn.org>
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From: robert bell [mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG]
Sent: Tuesday, September 13, 2016 10:13 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] A Black Hole of Patient Safety

Why not prioritize this? Triage task No 1.

Standardize the autopsy.  Find the money, and do one in 10 deaths in all hospitals or focus on one diagnosis.

Something like that.  But do something soon.

Rob Bell, M.D.


On Sep 13, 2016, at 7:46 AM, Mark Graber <mark.graber at IMPROVEDIAGNOSIS.ORG<mailto:mark.graber at IMPROVEDIAGNOSIS.ORG>> wrote:

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<mailto: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<mailto:ecburtonmd at gmail.com>>, "Dr. Kaveh Shojania" <kaveh.shojania at sunnybrook.ca<mailto:kaveh.shojania at sunnybrook.ca>>, "R.E.Horowitz" <r.e.horowitz at ucla.edu<mailto:r.e.horowitz at ucla.edu>>, robert.wachter at ucsf.edu<mailto:robert.wachter at ucsf.edu>
Cc: Mark Graber <mark.graber at improvediagnosis.org<mailto:mark.graber at improvediagnosis.org>>, Paul Epner <paul.epner at improvediagnosis.org<mailto:paul.epner at improvediagnosis.org>>
Resent-From: <Mark.Graber at Improvediagnosis.org<mailto: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<mailto:gdlundberg at gmail.com>

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